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Class "T ( E ^^ 

Book "?87 

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CORfRIGHT DEPOSm 



HYGIENE OF THE EYE 



BY 

WM. CAMPBELL POSEY, A.B., M.D. 

OPHTHALMIC SURGEON TO THE WILLS AND HOWARD HOSPITALS; PROFESSOR OF DISEASES 

OF THE EYE IN THE PHILADELPHIA POLYCLINIC) OPHTHALMOLOGIST TO THE 

DEPARTMENT OF PHYSICAL EDUCATION OF THE UNIVERSITY OF 

PENNSYLVANIA) CHAIRMAN OF THE COMMISSION ON 

CONSERVATION OF VISION OF PENNSYLVANIA 



120 ILLUSTRATIONS 




PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 



^^ 






COPTKIGHT, 1918, BY J. B. LIPPINCOTT COMPANY 



Elecirotyped and Printed by J. B. Lippincott Company 
The Washington Square Press, Philadelphia, U. S. A. 



OCT -8 1918 
©CI. A 5(1(5 '17 4 



PREFACE 

Sight is the most valuable of all the special senses and 
the author has endeavored to convey in the following pages, 
in language as free from technicalities as possible, how it 
may best be conserved, and the relation which the organ 
of vision bears to the general economy. Although general 
practitioners are doubtless more or less familiar with the 
substance of its contents, it is thought that a review of the 
more common diseases of the eye, with a description of the 
manner in which the eye is affected by the general health, 
and also how the latter may be influenced by eye-strain, 
will not be without value, both to the physician engaged in 
general practice and the general public. 

Vision plays such an important part in education that 
the chapters dealing with the refraction of the eye, the 
illumination and equipment of the school-room, and the 
general care of the eyes of the scholar should invite the 
interest of teachers and parents. 

Blindness and the diseases and conditions leading to 
it are fully discussed in its pages, together with the national 
movements which are being made towards its prevention; 
all of which the author hopes may lessen the labors of those 
who are so unselfishly leading the movement to diminish 
the number of blind in this country. 

In view of the increasing number of ocular injuries 
received by workmen in foundries, factories and elsewhere, 
particular attention is given to this important subject, as 
well as to the best means of preventing them — information 
which should be of value to those engaged with the problem 
of lessening the number of industrial accidents. 



iv PREFACE 

It is hoped by the author that the contents of the four 
chapters written by distinguished speciaHsts in the subjects 
which they discuss may prove of interest to ophthalmolo- 
gists as well as to general practitioners and laymen, as 
they contain information which should be of value to the 
specialist hitherto not available in condensed and popular 
form. Otherwise the author fears his professional col- 
leagues will find the work elementary and falling far short 
of what a comprehensive treatise on ocular hygiene treated 
fully from a scientific standpoint should be. He bespeaks 
their co-operation, however, in his attempt to convey to the 
popular reader a broader comprehension of the various 
phases presented by ocular anomalies and diseases. 

In conclusion, the author desires to express his obliga- 
tion to the National Committee for the Prevention of Blind- 
ness, for the loan of a number of photographs, notably 
those illustrating the chapter on wounds and injuries. 

The Author 

2049 Chestnut Street, 

Philadelphia, Pa. 

June 1, 1918 



CONTENTS 

CHAPTER PAGE 

I. Structure of the Eye and of the Parts Adjoining . . 1 
II. The Physiology of Vision — ^The Ophthalmoscope ... 12 

III. Defects or Anomalies of Refraction and Their 

Correction : Spectacles and Eye-glasses 26 

IV. Strabismus, Cross-eye or Squint 52 

V. The Influence of Optical Defects upon the Gen- 
eral System 59 

VI. School Life; Also Some Hints Regarding the Care 

OF THE Eyes in General 73 

VII. Artificial Lighting 101 

VIII. Daylight Illumination of Rooms and Buildings 

FROM AN Architectural Standpoint 117 

IX. Diseases of the Conjunctiva 127 

X. Diseases of the Eyelids, Lachrymal Apparatus, 

Cornea, Iris and Vitreous . 154 

XI. Diseases of the Interior of the Eye; Choroiditis, 

Retinitis, Optic Neuritis and Optic Atrophy 171 

XII. Some Visual Perceptions 180 

XIII. Cataract 185 

XIV. Glaucoma 196 

XV. The Participation of the Eye in Diseases of the 

General System 205 

XVI. Wounds and Injuries 233 

XVII. Effect of Certain Beverages and Drugs 273 

XVIII. Color-Blindness 279 

XIX. The Blind. Blindness from an Economic and 
Social Point of View. The Education and Em- 
ployment OF the Blind 283 

XX. The Popular Movement for Conservation of Vision 327 



V 



ILLUSTRATIONS 

FIG. PAGE 

1. Anterior Orifice of the Orbit with the Eyeball 2 

2. Muscles of the Right Orbit 4 

3. The Lachrymal Apparatus 6 

4. Section of Human Retina 8 

5. Crystalline Lens of New-born Child 9 

6. Camera Obscura of a Photographic Apparatus 13 

7. The Eye as a Camera 13 

8. Lenses 14 

9. Passage of Parallel Rays Through a Prism 15 

10. An Emmetropic or Normal Eye 16 

11. A Hypermetropic or Far-sighted Eye 16 

12. A Myopic or Near-sighted Eye 17 

13. Diagram To Illustrate Accommodation 18 

14. Types for Testing the Eye 19 

15. Binocular Field of Vision 22 

16. Loring's Ophthalmoscope 24 

17. Correction of Hypermetropia by a Convex Lens 28 

18.4. Near-sighted Boy Trying To Read Without Glasses 36 

18B. Same Boy with Glasses Properly Fitted 36 

19. Correction of Myopia by a Concave Lens 39 

20.4. View of School room, Showing How Room Looks to a Child 

with Abnormal Eyes after He Has Been Properly Fitted 

with Glasses 43 

20B. Blurred Picture of Schoolroom, Showing How Room Looks 

to a Child with Astigmatic Eyes 43 

21. Astigmatic Dial 44 

22. Cylindrical Lens 45 

23. Correct and Incorrect Positions of Lenses 49 

24. Showing an Increase in the Angle of Convergence of the 

Optic Axis in Consequence of an Extreme Rotation of 

One Eye 53 

25. A Schematic Diagram of the Cerebrospinal and Sympathetic 

Nerve Connections Between the Eye and the Stomach ... 63 

26. Compensatory Positions of the Head in Paralysis of Eye 

Muscles 67 

27. Expressions Indicative of Overaction and Weakness of the 

Muscles of the Eye 68 

28. The Compressed Brow on One Side and the Elevated One on 

the Other, Observable When the Eyes Are Not on the Same 

Horizontal Plane 68 

vii 



viii ILLUSTRATIONS 

29. Showing Torticollis from Vertical Deviation of One Eye .... 69 

30. Moiilthrop Movable and Adjustable School Chair 77 

31. The '* Princeton" Adjustable Desk and Chair 78 

32. Adjustable Desk and Chair 79 

33-34. Adjustable Racks 80 

35. Distortion of the Trunk While Working at a Too High Desk . 81 

36. Specimens of Correct Type for Books 85 

37. The Wrong Way To Use a Light 102 

38. A Good Way To Light a Desk 103 

39. The Wrong Way To Use a Table Lamp 104 

40. The Correct Way To Use a Table Lamp 105 

41. Dark Walls Waste Light and Prevent Diffusion 109 

42. A Common Type of Fixture Planned To Give Diffused 

Illumination Ill 

43. Another Type of Fixture Designed To Give Diffused 

Illumination 112 

44. A Well-considered Side- wall Light 113 

45. Proposed High School Building 121 

46. Showing the Use of Prism Glass To Deflect the Light in a 

Horizontal Direction 123 

47. Illustrating the Uses of Prism Glass with Different Angles 

of Reflection 124 

48. Negro Baby with Ophthalmia Neonatorum 130 

49. Corneal Abscess with Perforation 131 

50. Opaque Cornea After Ophthalmia Neonatorum 131 

51. Careless and Untrained Midwives Are Responsible for Much 

Infantile Blindness 135 

52. Nurse Applying Drops to Baby*s Eyes 136 

53. New-born Baby Being Treated in Hospital for Babies' Sore 

Eyes 137 

54. A Typical Case of Advanced Trachoma Showing Numerous 

Granulations 143 

55. Kentucky Girl Suffering from Trachoma 143 

56. Trachoma. Cicatrization Well Marked 143 

57. Trachoma. Cicatrization Almost Complete 143 

58. The Operation of Rolling or Expression 144 

59. Trachoma and Other Infectious Eye Diseases Contracted by 

the Use of Common Towels 145 

60. Pterygium 153 

61. Chalazion 156 

62. Congenital Ptosis 158 

63. Abscess of Lachrymal Sac and Mucocele . 160 

64. Little Girl Leaning Over Chair, with Head Buried in 

Cushion — Suffering from Corneal Ulcers 163 



ILLUSTRATIONS ix 

65. Hutchinson's Teeth 165 

66. Sarcoma of the Choroid 173 

67. Scintillating Scotoma in Migraine 183 

68. Swollen Opaque Lens After NeedUng 191 

69. Incision of the Cornea for the Removal of Cataract 192 

70. Expulsion of Lens Through Corneal Incision 192 

71^. Microphotograph of Anterior Part of a Normal Eye 200 

715. Microphotograph of Anterior Part of a Glaucomatous Eye 200 

72. Incising the Eye at the Corneal Margin for Iridectomy 201 

73. Iridectomy 202 

74. Coloboma of Iris After Iridectomy 203 

75. A Case of Exophthalmic Goitre 226 

76. Erosion of Cornea from Finger-nail Injury 236 

77. Adhesion of the Lid to the Globe After Lime Burn 237 

78. Perforating Wound of the Cornea with Prolapse of the Iris . . 238 

79. The Deadly Scissors and the Innocent Victim 239 

80. Rupture of the Eyeball 243 

81. Blood in Anterior Chamber Following Blow Upon the Eye . . . 244 

82. A Great Many Cases of Loss of Sight Have Been Reported 

as a Result of Curiosity of the Contents of Golf Balls .... 245 

83. Man With Eyesight Destroyed and Face Badly Disfigured 

by Burns From Molten Metal 248 

84. Eye Protection Used by Babbitt Workers 249 

85. Glasses Used by Workmen Pouring Babbitt 249 

86. A Foundry Chipping Yard 250 

87. Glasses Used by Workmen Chipping WTieels; also Burlap 

Guard To Catch Flying Chips of Steel 250 

88. Man With Hood of Brass Wire, Standing Before Furnace ... 251 

89. Water Gauge Glass on Boilers, Protected With Brass 

Casting 252 

90. Glasses Used by Operator at Emery Wheel 253 

91. Hammer, Sho^ving Chip 254 

92. Warning Placard . 255 

93. Mask Used by Operator To Protect Eyes and Face While 

Using Electric Welding Machine 257 

94. Glasses Used by Open Hearth Employees To Protect Eyes 

While Looking in Open Hearth Furnaces 258 

95. Electric Cataract 259 

96. Three Bottles Containing Wood Alcohol Sold by Druggists 

in New York City 262 

97. Steel Chip in Lens 265 

98. Patient in Position Before Giant Magnet 266 

99. Skiagraph Showing Foreign Body in Eye 267 



X ILLUSTRATIONS 

100. Taking X-ray for Supposed Foreign Body in Eye 268 

101. The Pennsylvania Institution for the Instruction of the 

BUnd, Overbrook, Philadelphia 290 

102. The Swimming Pool 293 

103. One Hundred Yard Dash. Start 295 

104. One Hundred Yard Dash. Finish 295 

105. School Gardens in June 297 

106. Modeling 299 

107. The Workroom 301 

108. Facsimile of Type Used by Valentin Haiiy 304 

109. American Braille Alphabet 306 

110. Interlining Braille Slate 307 

111. Hall Braille Writer. 308 

112. Facsimile of Pencil Writing in ** Square Hand" by a Totally 

Blind Girl 309 

113. Form Study and Map Drawing 311 

114. Senior Pupils Teaching Seeing Pupils, at the Clavier and 

Piano 316 

115. Senior Girls with Their Housemother in Their Cottage 

Sitting-room 322 

116. Piano Tuning and Repairing Is One of the Most Lucrative 

Occupations for Capable Blind Men 325 

117-118. Warnings Published by National Committee for the 

Prevention of Blindness 330 



PLATES 

I. Horizontal Section of the Eyeball 6 

II. Variations of the Fundus. Inflammations of the Retina. 
Atrophy of Nerve in Locomotor Ataxia. Choked Disc in 
Tumor of the Cerebrum 24 



HYGIENE OF THE EYE 

CHAPTER I 
STRUCTURE OF THE EYE AND OF THE 
PARTS ADJOINING 

To render the descriptions of the various affections 
which will be treated of in the following pages more com- 
prehensible, it has seemed desirable to give some intro- 
ductory account of the anatomy and physiolog}^ of the 
eyes and their appendages. Naturally, any attempt at a 
complete or technical description of either of these sub- 
jects would be foreign to the scope of this treatise, and 
an effort will be made to present them in the briefest manner 
compatible with clearness. 

Such a delicate organ as the eye necessarily demands 
most careful protection, not only from external injury, 
but also from diseases of contiguous structures. Against 
the former, nature has amply provided by furnishing a 
bony framework into which the eye is set, so that only 
its anterior one-third is exposed, and even this portion has 
the covering of the lids and the interlacing eye-lashes, to 
protect it when occasion demands. To give expression to 
the w^orkings of the mind, and to endow the countenance 
with charm and intelligence, the exposed part of the eye 
has been made the most beautiful of all the structures of 
the body and has well earned the designation of the poet 
as " the mirror of the soul." 

The bony receptacles in w^hich the eyes are lodged, the 
orbits, are cone-shaped, with their widest portion directed 



2 HYGIENE OF THE EYE 

forward, and as the long axis of each cone is more di- 
vergent at its opening than at the apex, a maximum of 
rotation is afforded to the eyes as they are pulled in various 
directions by the action of the group of muscles with which 
each is provided (Fig. 1) . In addition to the eyeball and 
its muscles, the orbit contains a thick bolster of fat, which 
surrounds the globe, protecting it from injury and per- 
mitting of its free rotation by the ocular muscles. The 




Fig. 1. — Anterior orifice of the orbit with the eyeball. Natural size. The tendons of the 
four recti muscles are cut off near their insertion upon the eyeball, but the interior oblique, oi, 
and the tendon, os, of the superior oblique are left entire. 

configurement of the orbit depends in large measure upon 
the shape of the skull and varies in different individuals 
and in different races, being shallow in races with skulls 
short in the anteroposterior axis, as exemplified in the 
Indian, and deep where the same axis is elongated, as may 
be noted in many European skulls. As the shape of the 
orbit determines in large measure the form of the eyeball, 
and, as we will see later, the state of the refraction in 
each eye is dependent upon its length, it follows that near- 



STRUCTURE OF EYE AND PARTS ADJOINING 3 

sightedness and far-sightedness are often the expression 
of racial pecuharities of structure. 

While the walls of the orbit are thin, to give less weight 
to the skull, their margins are dense and strong, to re- 
ceive the force of blows. This is particularly true of the 
upper margins, where the protective power of the brow is 
further augmented by a cushion of hair, the eyebrow, which 
is formed of muscle and thick skin, covered with stiiF hairs. 
The brow forms a conspicuous setting for the eye and 
enters largely into facial expression. It also affords pro- 
tection, by shedding perspiration. 

With but one exception, the eocternal muscles of the 
eye, six in number, arise from the apex of the orbit and 
are attached to the globe near its equator. This arrange- 
ment permits of the free movement of the eye in all direc- 
tions, while the one muscle which has its origin near the 
opening of the orbit is concerned chiefly with its easy 
rotation ( Fig. 2 ) . These muscles receive their stimuli 
from nerves which, together with the principal blood-ves- 
sels, gain access to the orbit through a fissure in the apex 
of the orbit. Another hole in the same position, the optic 
foramen, permits the passage of the optic nerve with the 
chief retinal blood-vessels into the skull. The muscles of 
both eyes work in perfect harmony with one another, and, 
by means of a wonderful complex mechanism of correlated 
activity, rotate the eyes, either subconsciously or at the will 
of the individual, in all directions. Any considerable inco- 
ordination in their action is productive of double vision, 
and the nice parallelism which is maintained by the per- 
fect balance of all the muscles is destroyed and the affected 
eye turns or squints (see p. 52). 

The eyelids when closed form a perfect curtain for the 



4 HYGIENE OF THE EYE 

eye, and when open an attractive setting for the organ of 
vision. The lashes, with their graceful curve, are decora- 
tive as well as protective to mechanical injury, and when 
the lids are partially closed, their interlacing without ex- 
cluding vision serves as a protection against excessive light. 
They attain their maximum growth in about five months 
and then drop out, being succeeded by new ones. Inflam- 




FiG. 2. — Muscles of the right orbit. ("Motor Apparatus of the Eye," Stephens, Courtesy 

F. A.Davis Co.) 



matory conditions of the edge of the lids sometimes cause 
the incoming lashes to assume a wrong direction and to 
turn inward against the eye. They are then commonly 
known as " wild hairs," and cause great distress and may 
even give rise to serious inflammation of the eyeball. 
Assuming that other inflammatory conditions of the eye 
which are attended by sensations of pricking and irrita- 
tion are also caused by wild hairs, it happens not infre- 
quently that the ignorant pull out their lashes in the hope 
of obtaining relief from the annoying symptoms, a use- 



STRUCTURE OF EYE AND PARTS ADJOINING 5 

less procedure, as the lashes in such instances are not at 
fault. 

The movements of the lids are performed almost en- 
tirely by the upper, the lower being almost stationary. 
Upon the width of the opening between the lids depends 
the apparent size of the eye and the expression of the in- 
dividual. Racial characteristics find expression in the 
almond eye of the Mongolian. In certain diseases of the 
eye and the nervous system, the upper lids droop, giving 
an expression of drowsiness and frequently necessitating 
the throwing back of the head to enable the rays of light 
to gain entrance to the pupils. 

The eyelids, which are composed of muscle, elastic 
tissue, and plates of cartilage which give form and firm- 
ness to the lids, are covered by skin, which is but loosely 
attached to the sublying tissues. This laxity of the super- 
ficial tissues accounts for the great swelling which fre- 
quently attends inflammations or follows injury of these 
structures, and permits of the pufiiness under the lower 
lids which frequently accompanies diseases of the heart 
and kidneys. 

The thin, delicate tissue, the conjunctiva, which covers 
the anterior part of the globe and also lines the lids, is 
continually lubricated by tears derived from the lachrymal 
gland, a secreting organ the size of a filbert, hidden under 
the outer portion of the roof of the orbit, and by mucus 
derived from the conjunctiva itself and from a series of 
small glands embedded in the edge of the lids. After 
lubricating the eye and the conjunctival sac, the secre- 
tions are sucked by two small apertures situated upon the 
inner portion of each lid into the tear sac, with which they 
are connected by two fine tubes. This sac, the size of a 



6 HYGIENE OF THE EYE 

small pea, is situated just below the ligament which con- 
nects the lids with the orbit, so that its emptying is facili- 
tated not only by the contraction of its own muscular coat, 
but also by the tension exerted upon it by the ligament of 
the lids during the act of winking. The lachrymal sac 
empties into the nose, through a bony canal at the lower 
inner portion of the orbit. This canal and sac are lined by a 
mucous membrane continuous with that of the nose and 



Superior lacrimal gland 
Inferior lacrimal gland 




Upper eyelid partly 
divested of skin 



Upper punctum 



Lacrimal sac, near it9 
fundus 

T. . X ■ ^ I II iiwiMiii I Common duct, formed 

Ducts from supenor ^ ^^^^^^^tIIpO^^^^MIL by junction of upper 

gland ^/^///Afllrv \^ ^^^^^^MT and lower ducts 

Lower punctum 
Naso-lacrimal duct 



Fig. 3. — The lachrymal apparatus. ("Modern Ophthalmology," Ball, F. A. Davis Co.) 

of the conjunctival sac, which accounts for the sympathetic 
watering of the eye in so many nasal affections (Fig. 3) . 

The eye itself is spheroid in form and about an inch in 
diameter, being somewhat longer in its anteroposterior 
than its vertical axis. It is suspended in the orbit by its 
muscles and by a series of membranes or fascia to the walls 
of the surrounding orbit. The layer of fat referred to 
above fills out the remaining orbital space. 

The outer layer, or envelope, the sclerotic, is a firm, 
opaque, tough membrane, into the anterior part of which 
the transparent cornea is set. The sclerotic maintains the 
form of the eyeball and serves for attachment of the 



PLATE I. 




CANAL OF/ 
SCHLEMN 

C/UARY 
BODY 



Horizontal section of the eyeball. Magnified about ZYi times (see PP- 7-10). ("Manual of 
the Diseases of the Eye," Charles H. May, M.D.; Wm. Wood <k Co.) 



STRUCTURE OF EYE AND PARTS ADJOINING 7 

muscles which move the eye. That portion immediately 
smrounding the cornea and which is alone visible, forms 
the so-called " white of the eye," the rest being hidden be- 
hind the conjunctiva and orbital tissues. The cornea is 
also tough and resisting, but perfectly transparent, to per- 
mit the passage of rays of light into the eye (Plate I) . It 
may be designated as " the window of the eye." Its outer 
sm-face is smooth and preserves a high degree of polish, 
and, being curved, returns, as a convex mirror, an erect 
image of diminished size of any object before it. 

Lying within the sclerotic, is the choroid, a membrane 
rich in blood-vessels and pigment. The blood-vessels 
nourish the interior of the eye and the pigment aids in the 
absorption of excessive light. The quantity of pigment 
varies, being plentiful in brunettes and sparse in blondes. 
In albinos it is entirely absent. The choroid does not ex- 
tend quite so far forward as the sclerotic, and merges 
anteriorly into the ciliary body. 

The third and essential coat is the retina. This is a 
delicate sheet of nervous tissue, continuous with the brain, 
through the medium of the optic nerve and its cerebral pro- 
longations, and the rest of the eye may be regarded merely 
as a mechanism for its protection and means of exposure 
to external impressions ( Fig. 4 ) . The light-perceiving 
elements of the retina are arranged in ten distinct layers, 
held together by a connective-tissue framework. The most 
important layer is that of the rods and cones, the latter 
elements being especially concerned in the perception of 
visual sensations, as these bodies are alone represented in 
the macular region, a very minute area upon which the 
rays concerned with the most direct and acute vision are 
focussed. External to the laver of rods and cones is the 



8 HYGIENE OF THE EYE 

pigment layer, in which is stored the retinal purple, a 
photochemical substance which absorbs light and is con- 
cerned in the transformation of the rays into visual im- 
pulses. Just what the nature of this transformation is has 
not been clearly determined, but, of course, there is no 



ir 



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o 



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'" ( )s'0/^,^, 



^0 O'OX <-A .'- - 



■ — a 
—b 



— b 
—a' 
— c 







i^«^ 






.^'/j 



Fig. 4. — Section of human retina (Bohm and v. Davidoff) : a, a', outer and inner segments 
of rods; b, b', outer and inner segments of cones; c, membrana limitans externa; d, outer nuclear 
layer; c, outer plexiform layer; /, inner nuclear layer; g, inner plexiform layer; h, layer of ganglion 
cells; i, fibre layer. Magnified 700 diameters. 

actual picture capable of perception by another person 
formed there. 

The claim sometimes made, therefore, of the possibility 
of detecting by posthumous examination of the retina the 
object last regarded before death, is extravagant and 
absurd. 

The remaining portions of the eye are adapted to the 
proper focussing of the rays of light entering the eye 
through the cornea upon the retina, and in the regulation 



STRUCTURE OF EYE AND PARTS ADJOINING 9 

of the amount of light entering the eye. The chief of these 
is the crystalline lens ( Fig. 5 ) . This structure is a double 
transparent convex lens or ordinary magnifying glass, but 
of such consistency that its convexity may be readily 
altered. It consists of connective layers composed of 
minute fibrils, the outermost layers, or cortex, being softer 
than at the central zone, or nucleus. As age advances, the 
lens becomes harder and more resistant. It is contained 
within an elastic covering and is suspended in the anterior 




Fig. 5. — Crystalline lens of new-born child, seen from the side, showing the course of 
the lens fibres. (Arnold.) Magnified 6 diameters. 

part of the eye by a delicate ligament, a fine transparent 
structure of fibrous tissue, and surrounded by a small cir- 
cular structure, the ciliary body, the termination of the an- 
terior extremity of the choroid coat. This body is divided 
into two portions, a circular band of muscular tissue, the 
ciliary muscle, and the ciliary processes. These latter, 60 
or 70 in number, merge with the anterior portion of the 
choroid and possess the power of pulling that membrane 
forward. The ciliary body is a structure of great impor- 
tance, as will appear later, for upon its action depends 
the alteration in the shape of the crystalline lens and the 
changing focus of the eye. 



10 HYGIENE OF THE EYE 

The lens rests posteriorly in a cup-shaped depression 
in the vitreous humor, a transparent gelatinous structure 
which occupies four-fifths of the interior of the ball. This 
humor fills out the form of the eyeball and gives support 
to the retina, spread over its outer surface. 

The amount of light entering the eye is regulated by 
means of a circular curtain, the iris, its central aperture 
forming the pupil. The iris lies upon the front of the 
lens, its base of support and action being at the margin 
of the posterior surface of the cornea, and the anterior 
portion of the ciliary muscle. In addition to muscle fibres, 
the iris contains pigment, the quantity of which determines 
the color of the eye, the designation of the eyes as gray, 
blue or black depending upon that factor. In albinos, the 
pigmentation of the iris is absent, and the pinkish hue is 
dependent upon the reflection through it of the red blood 
in the vessels of the choroid. All eyes are blue at birth, 
the commencement of permanent coloration taking place 
about the sixth week. There is no truth in the popular 
idea that dark eyes are stronger than light ones, except 
in so far as they are better protected against excessive 
light. It is a wise provision of Nature, that among South- 
ern races dark eyes prevail, the better to protect against 
the glare of a tropical sun, while in the North, light eyes 
predominate. 

The circular aperture in the iris, the pupil, is adapted 
for the transmission of light into the eye, its size constantly 
varying in response to variations in the quantity of light 
which falls upon it. The change in the shape of the pupil 
is effected by a double set of muscles in the iris, one of 
circular fibres, contracting to make the pupil small in the 
light, and one of dilating powers, to enlarge the pupil in 



STRUCTURE OF EYE AND PARTS ADJOINING 11 

darkness. The pupil varies in size in different individuals, 
and at different ages, growing smaller as age advances. 
The pupil is larger, also, in near-sightedness than in far- 
sightedness. Local affections within the eye, as well as 
diseased conditions elsewhere in the body, affect its size; 
various drugs have the same power also. 

The space between the iris and lens and the arching 
surface of the cornea is filled with an aqueous humor ^ which 
has some refracting properties. The cornea and vitreous 
also possess like qualities. These are constant, and but 
slight in comparison with those of the lens. 

The eyeball is richly supplied with blood-vessels and 
nerves, apart from the great nerve of sight, the optic, and 
it is by means of some of these latter that the change in 
the size of the pupil is accomplished, acting under stimuli 
from the brain centres. The chief source of vascular 
supply to the retina is by means of a small artery which 
enters the eye through the centre of the optic nerve. In 
case of sudden stoppage of this vessel by a clot, instant 
blindness ensues. 



CHAPTER II 

THE PHYSIOLOGY OF VISION— THE 
OPHTHALMOSCOPE 

Of all the special senses, sight, perhaps, is the most 
valuable and highly prized. It comprises the perception 
and translation of impressions derived from external ob- 
jects into cerebral conceptions. The explanation of the 
visual act must therefore include the manner by which 
impulses are conveyed from the exterior to the brain 
centres, and something at least regarding the nature of the 
impressions. How physical impulses are transformed into 
vision we cannot say, nor have we, indeed, any knowledge 
of other kinds of perceptions. 

From an optical standpoint, all objects in nature are 
divided roughly into luminous and non-luminous bodies; 
light emitted from the former or reflected from the surface 
of the latter moves in straight lines, and the smallest con- 
ceivable line of light is called a ray. Of these rays we will 
speak more hereafter. It will suffice at this time to say that 
the great function of the eye is to collect these rays from 
surrounding bodies, to focus them upon one of its parts, 
the retina, whence the impressions are conveyed along the 
optic nerve and higher brain tracts to the various visual 
centres. The eye, therefore, resembles in its action a pho- 
tographer's camera, of such intricate and wonderful con- 
struction that it is always exposed for the receipt of im- 
pressions from all distances, and can act either alone or in 
harmony with its fellow, with a swiftness and accuracy that 
no mechanical device can even approach, much less equal. 

12 



PHYSIOLOGY OF VISION— THE OPHTHALMOSCOPE 13 

In the camera, images of external objects are focussed 
upon a sensitive plate and become permanent in conse- 
quence of chemical changes induced by light; in the eye, 




Fig. 6. — Camera obscura of a photographic apparatus. AB, object; Z>, diaphragm for 
shutting off too divergent rays; L, lens for refracting the rays so that they will form the image 
ab upon the sensitive plate R. 

they fall upon the retina, where, after undergoing bio- 
chemical change, they are conveyed to the visual centres in 
the brain by the optic nerve. The eyeball itself, therefore, 




Fig. 7.— The eye as a camera. AB, object; C, cornea, where the rays undergo a first refrac- 
tion; D, the iris, that acts as a diaphragm for shutting off too divergent rays; L, lens, where the 
rays are again refracted; R, retina, upon which the image ah is projected; a'fe' represents the 
surface of a hypermetropic eye, and shows that the rays are not completely focussed, and conse- 
quently the image must be blurred and indistinct; o"b" represents the surface of a myopic eye, 
and shows a similar condition. 

does not see, the act of vision being performed by the 
brain. Figs. 6 and 7 compare the mechanism of a camera 
with that of the eye. The sclerotic represents the sides 



14 



HYGIENE OF THE EYE 



of the box, the choroid its blackened inner surface, the 
pupil forms the opening, and the crystalline lens and 
cornea the focussing lens (e) , The iris serves as a dia- 
phragm. The rays of light fall in the one case on the 
sensitive plate, in the other on the retina. As the rays 
of light cross in the eye, the retinal picture is an inverted 
one, just as is the image in the magic lantern. The trans- 
position of the image doubtless occurs in the brain, though 
there are some who assert that the righting process takes 
place in the retina itself. 

Lenses. — A lens may be defined as a portion of glass 





Fig. 8. — A, plano-convex: one side convex, the other plane. B, double convex: both 
sides convex. When both sides are equally convex, as represented in the figure, the lens is 
called biconvex. C, concavo-convex: one side concave, the other more convex. D, plano- 
concave: one side concave, the other plane. E, double-concave: both sides concave. When 
they are equally concave, as in the figure, the lens is called biconcave. F, convexo-concave: 
one side convex, the other more concave. Either C ot F ia called a meniscus, or periscopic lens. 

or other substance capable of transmitting light rays 
bounded by one or more curved surfaces. Lenses that are 
thickest at the centre are designated as convex lenses, those 
thinnest at the centre as concave lenses. Convex lenses 
have the property of collecting light rays, concave lenses 
of dispersing them. According to the degree in which they 
divert rays from their original source, lenses are designated 
as strong and weak, the former bringing rays quickly to a 
focus, the latter having their focus at a greater distance. 
The standard now universally adopted in the notation of 



PHYSIOLOGY OF VISION— THE OPHTHALMOSCOPE 15 

lenses is based upon the metric system and the unit from 
which the gradations in the strength of lenses is reckoned 
is the Dioptre, i.e.„ the focussing power required to bring 
parallel rays to a focus at the distance of 1 metre. A lens 
with twice this strength is designated as a 2 D. lens, and 
has a focal distance of one-half metre. An 0.50 D. lens is 
one with a focal distance of 2 metres (Fig. 8). 

Lenses may be either spheric or cylindric. In the 
former, light is refracted equally in all its planes, in the 
latter, in one meridian only. 

Prisms. — By a prism is meant a section of glass con- 
sisting of two plane surfaces so inclined to each other that 




Fig. 



-Passage of parallel rays through a prism. 



they form an angle. As it is the property of prisms to 
deviate rays of light from the apex toward the base of the 
prism, a prism placed before either eye with its base to- 
ward the nose will deflect rays of light entering the eye, 
and lessen convergence effort (Fig. 9). Prisms may be 
ground into the lens, correcting any kind of refraction 
error, and as their base may be placed at any axis, and 
their strength accurately prescribed, they form one of the 
most valuable means of correcting eye-strain in the ocu- 
list's armamentarium. Prisms are not only of service in 
removing the strain from weak muscles, but are often em- 
ployed in exercising such muscles, the base of the prism in 



16 HYGIENE OF THE EYE 

such cases being opposed in direction to the action of the 
muscle which is to be strengthened. 

All luminous rays reflected from a source at a dis- 
tance greater than 15 or 20 feet are considered to be 
parallel. When the object from which light is reflected is 
brought nearer, rays entering the eye are divergent and 



Fig. 10. — An emmetropic or normal eye. Parallel rays a and & are focussed upon the retina, while 
divergent rays, as those proceeding from the point B, come to a focus behind the retina. 

require to be more strongly bent or collected before they 
focus upon the retina. This focussing property, of bend- 
ing parallel rays of light from the distance and diverging 
rays from near objects so that they meet upon the retina, 
is termed refraction. 

All eyes are not of equal length, some being shorter 




FiQ. 11. — A hypermetropic or far-sighted eye. Parallel rays converge behind the retina, Rays 

must be convergent in order to focus there. 

and some longer than the average, or what may be con- 
sidered to be the standard, eye. According, therefore, 
to this variation in length, ocuhsts designate by the term 
emmetropic, the eye of 7i07^mal length (Fig. 10), in which 
rays of light entering the eye from a distance are brought to 
a focus exactly on the retina. By the hypermetropic or far- 
sighted eye (Fig. 11) is meant too short an eye, one in 



PHYSIOLOGY OF \^SION— THE OPHTHALMOSCOPE 17 

which similar rays of hght are brought to a focus behind 
the retina, and by myopic or near-sighted eye (Fig. 12), 
too long an eye is designated, one in which the rays from a 
distance are focussed in front of the retina. 

Xot only may eyes vary in length, but, owing to a lack 
of uniformity in the curvature of the cornea, different 
meridians of the same eye have a different focus. In this 
refractive condition, which is termed astigmatism, rays of 
light w^hich pass through the meridian of greatest con- 
vexity are brought to a focus sooner than those passing 
through the meridian of least curvature. According to the 
degree of corneal asymmetry, the type of astigmatism may 
vary. In simple astigmatism, for example, one of the 




Fig. 12. — A myopic or near-sighted eye. Parallel rays converge before reaching the retina. 
Rays must be divergent in order to focus there. 

meridians is emmetropic, the other hypermetropic or 
myopic. In compound astigmatism, both meridians are 
faulty, but unequal in degree. In mixed astigmatism, one 
meridian is hypermetropic, the other myopic. 

Accommodation. — In describing the various parts of 
the eye, the crystalline lens was designated as a transpar- 
ent biconvex lens, enclosed in a fibrous capsule, adaptable 
to change of shape, by action of the circular structure which 
surrounds it, the ciliary body. Unlike the camera, whose 
lenticular focal distance may be changed by movement of 
the sensitive plate backwards and forwards, the length of 
the eyeball is fixed and constant, and alterations in its 
focussing power performed by a change in strength of the 



18 



HYGIENE OF THE EYE 



refracting surfaces within the eye (Fig. 13) . As has been 
stated, hght rays coming from a distance greater than 15 
or 20 feet are parallel; those emanating from an object 
situated nearer are divergent. To change the focus of the 
eye, therefore, from the perception of distant objects to 
those for near, its refracting power must be increased, and 
the convexity of the crystalline lens increased by action of 
the ciliary muscle. This adaptability of the eye is known 
as the power of accommodation, and is made use of when- 
ever there is the slightest change in the distance of any 




PAR 



NEAR 



Fig. 13. — Diagram to illustrate accomraodation (after Helmholtz) . C.P., ciliary process; 
7, iris; Sp.l, suspensory ligament; Z. cm., longitudinal ciliary muscle; c.c.m., circukr ciliary 
muscle; c.S., canal of Schlemm. The left half represents the arrangement for viewing far 
objects and the right half for viewing near objects. (Foster's "Text-book of Physiology," The 
Macmillan Company.) 

near object we look at. As life advances, accommodation 
steadily declines. At 30 years of age, half of its power is 
gone and at 45 years it is so weakened that small objects 
near at hand are not perceived without additional focussing 
power. At 60 years, accommodation is practically nil. 
This decline in power is due to the increasing hardness in 
the lens already referred to, in consequence of which the 
ciliary muscle loses its power to increase its convexity. 
This loss in power of accommodation due to advancing 
years is termed presbyopia or old sight. 

Visual Acuity. — ^The normal acuteness of vision has 



PHYSIOLOGY OF VISION— THE OPHTHALMOSCOPE 19 

been determined to be the power the eye has of distinguish- 
ing objects which subtend an angle of 5' upon the eye. 
With this as a basis, Snellen, a distinguished Dutch oph- 
thalmologist, constructed a series of letters made to con- 
form to this standard. The accompanying diagram (Fig. 
14) demonstrates that an object, in order to subtend the 
same angle, must be larger the farther it is removed from 
the eye. In conducting the test for visual acuity, a card 
containing graduated series of letters of different sizes is 
placed 6 metres distant from the observer and record made 
of the smallest line of letters which the observer is able to 
distinguish with each eye separately. If vision is normal, 



/ \ _^^?r^^ 




D-60 

J 


viy 



Fig. 14. — These types are so designed that the largest type shoyld be seen at 60 metres 
by the normal eye, and the types range from this down to a size i-isible not farther off than 
6 metres. 

the line of letters designated as No. 6 will be distinguished 
without difficulty. Lower degrees of acuteness indicate 
some error in refraction or disease of the eye or of the 
centres of sight in the brain. In general, the visual acuity 
is expressed by a fraction, the numerator of which is the 
distance at which the test is conducted, the denominator, 
the line of type designated, i.e., vision 6/12 means that the 
acuity is but one-half of normal, the line marked No. 12 
on the card being seen at a distance of 6 metres. 

The Field of Vision. — Thus far we have been con- 
cerned with a description of direct vision, with the focussing 
and refraction of rays which entered the eye in its principal 
axis and are brought to a focus upon the centre of the 



20 HYGIENE OF THE EYE 

retina, the macula lutea, so-called. Though less sensitive, 
the periphery of the retina is also capable of receiving im- 
pressions and transmitting them through the retina to the 
optic nerve and thence to the brain. This peripheral per- 
ception is termed indirect vision, and by it the eye is made 
conscious of objects outside the area of direct vision. The 
area embraced by direct and indirect vision is designated as 
the field of vision, and varies in extent according as the eye 
is directed upon a near or far object. By means of this 
function, there is a visual consciousness of a wide area of 
objects seen indirectly, and when this area is lessened by 
disease within the ejQ or impairment of the visual tracts 
and centres governing vision, the perceptive powers of the 
individual are greatly restricted. 

If an individual station himself with his back to a 
window at a distance of two feet from a screen, and with 
one eye blindfolded direct his gaze upon his finger pressed 
against the screen directly in front of his eye, while with 
his free hand he brings a small square of white paper from 
the extreme periphery slowly inwards towards the finger 
point at which the eye is directed, the first conscious ap- 
pearance of the paper will determine the extent of his 
visual field in that particular meridian, and if this pro- 
cedure be repeated until all the meridians encircling the 
fixing finger be tested, he may map out roughly the 
entire extent of his visual field. If small pieces of colored 
paper are then substituted for the white, he will obtain the 
dimensions of what is termed the color field. This will be 
noted to be peripherally smaller than that for white, and if 
some designation of the point at which the colors are first 
seen is recorded on the screen, it will be noted that these are 
not all seen at the same point, but that blue will be per- 
ceived before red and red before green, etc. 



PHYSIOLOGY OF \^SIOX— THE OPHTHALMOSCOPE 21 

Defects in the visual field may vary from loss of the 
entire field of indirect or peripheral vision, with the con- 
servation of that of the central or fixation point alone, to 
the production of small blind areas or scotomas, scattered 
throughout the field. These minute blind spots, produced 
by disease, must not be confused with the physiological 
blind spot (Mariotte's blind spot) which corresponds to 
the position of entrance of the optic nerve within the eye, 
and which is situated somewhat to the outer side and below 
the fixation point. 

Loss of half of the field of vision, termed hemianopsia, 
especially when associated with a corresponding loss in the 
fellow eye, is veiy significant of brain disease, and in asso- 
ciation with a speech defect often follows apoplectic at- 
tacks. Blindness in the outer halves of the field of vision 
of both eyes is significant of disease of the pituitary body, 
and is often seen in connection with giantism and certain 
sexual characteristics. 

Each eye not only possesses its own field of vision, but 
one in common vAih. the fellow^ eye. The simultaneous use 
of both eyes is called binocular vision, and it is by the har- 
monious blending of images focussed upon corresponding 
parts of the two retinae that the brain receives but a single 
impression. By means of binocular vision, we are enabled 
to form a much better impression of distances and of the 
form or solidity of objects. The accompanying diagram 
(Fig. 1.5) demonstrates the area of the combined fields of 
vision. 

The determination of the extent of the visual field, more 
accurately determined, and registered by an apparatus 
termed the perimeter, is in common use by all oculists and is 
of inestimable value, not only in determining the nature and 
extent of intra-ocular diseases, but also the location of many 



22 HYGIENE OF THE EYE 

affections within the brain which affect the centres of sight. 
Ocular Muscles. — ^The range and extent of the field 
of rision is greatly increased by the rotation of the eyes by 
the extra-ocular rnuscles. Each eye moves in perfect 
unison with its fellow, and always with the maintenance of 
symmetrical points of the retinal images. If this har- 
monious action of the muscles moving the eyes be disturbed, 
single vision is no longer possible, and double vision re- 
sults, usually with some apparent deviation of the eyes 
from the normal parallelism of their axes. In other words, 
the eyes are crossed. This is observed in paralyses of one 




Fig. 15. — Binocular field of vision. (Mcser.). The line L bounds the field of vision of the 
left eye, the line R that of the right eye. The central white area Ifr marks the field of vision 
common to both eyes. 

or more of the eye muscles, such as occurs in consequence 
of some serious local or systemic disease. 

Less serious but often no less disturbing phenomena 
are occasioned much more frequently by slighter anomalies 
in the structure or nerve supply of the ocular muscles. In 
this class of cases, the heterophorias, so-called, there is no 
apparent departure from the harmonious dual action of the 
eyes, and single vision is still maintained. This main- 
tenance of single vision and the avoidance of double vision 
is attained, however, only after severe effort upon the part 
of the weak muscles, and a chain of symptoms is evoked 
which is designated under the term of muscular weakness 
or muscular asthenopia. Dizziness, headache, digestive 



PHYSIOLOGY OF VISION— THE OPHTHALMOSCOPE 23 

disturbances, and ocular discomfort at all distances, are 
some of the subjective symptoms evoked by these latent 
muscle errors. A consideration of true cross-eye, squint, 
or strabismus will be given later. 

The Ophthalmoscope 

Prior to 1851, the interior of the eye had never been 
explored and there was no knowledge of the conditions 
which interfered with vision other than those apparent by 
inspecting the anterior segment of the eye. In this year, 
however, von Helmholtz, the great physicist, produced an 
instrument termed the ophthalmoscope, by means of which 
it became possible to illuminate the fundus or back part of 
the eye, and to study under considerable magnification the 
many diseased conditions which were formerly the sub j ects 
of theoretical speculations. This discovery was undoubt- 
edly one of the greatest achievements in physical science, 
and, as will presently be learned from the description of 
what the ophthalmoscope unfolds, has been of incalculable 
benefit to medicine. 

The ophthalmoscope consists primarily of a concave 
silvered mirror with a central perforation, behind which are 
placed a number of convex and concave lenses set into a 
disc, which is capable of rotation, so that any one of the 
series of lenses may be brought before the aperture (Fig. 
16) . The ophthalmoscopic examination is made in a dark- 
ened room, the patient being placed in front and somewhat 
to the side of a single source of illumination. The ex- 
aminer, stationing himself before the patient, with the cen- 
tral aperture in the mirror held close to his eye, collects the 
rays of light from the lamp upon the mirror of the oph- 
thalmoscope and directs them upon the eye to be examined. 
The patient is then requested to direct his gaze directly in 



24 HYGIENE OF THE EYE 

front of him, while the examiner, with relaxed accommoda- 
tion, slowly approaches to within a few inches of the pa- 
tient's eye, keeping the pupil steadily illuminated. To one 
versed in the art of ophthalmology, the interior of the eye 
is at once visible, and may be studied without inconvenience 




Fig. 16. — Loring's ophthalmoscope; front view. The perforated mirror in this case 
is cut into a quadrangular shape, so that it can be rotated slightly from side to side (tilting 
mirror). This is to make the reflection of light less oblique in using the direct method. The 
lower disc contains a series of lenses which can be rotated by the pressure of the finger on the 
serrated edge of the disc, so that any desired lens can be brought in front of the sight-hole. 
Usually there is added a quadrant on the back, containing additional lenses, which being super- 
imposed over those in the revolving disc make a great variety of combinations. 

or strain to the patient or observer for a protracted intei^al. 
By means of the lenses which may be brought into the line 
of vision, it is possible to measure with considerable ac- 
curacy any errors of refraction present. 



PLATE II. 




A, the ttlbinotic fundus; albino and light blonde. B, the tessellated fundus; brunette (see p. 25). 
C, albuminuric retinitis and neuritis orcurrinK in pregnanfy (see p. 210), D, atrophy of retina 
nerve and choroid following disseminated chorioretinitis luetica (see p. 172). E, atrophy of optic nerve 
in locomotor ataxia (see p. 232). F, choked disc in tumor of the cerebrum (see pp. 178-228). 
(Posey and Spiller.) 



PHYSIOLOGY OF VISION— THE OPHTHALMOSCOPE 25 

Precise measurement of the refraction of the eye is 
accomplished by observing the direction in which the Hght 
appears to move across the pupil as the mirror held close to 
the observer's eye is rotated in the vertical and horizontal 
meridians. In the application of this test, which is termed 
retinoscopy, or the shadow test, the observer stations himself 
at a metre's distance from the patient, and superimposes 
lenses of various kinds and degrees before the patient's eye 
until the requisite change in direction of the movements of 
the light is attained. To insure accuracy, complete pupil- 
lary dilatation by the instillation of some drug to accomplish 
this purpose is necessary. When properly performed, this 
test is one of exceeding accuracy, and enables the examiner 
to ascertain not only the amount of far- and near-sighted- 
ness present, but also the axis and degree of the astigmatism. 

The picture of the interior of the eye revealed by the 
ophthalmoscope is one of great beauty. Varying in shade, 
depending upon the amount of pigmentation, being lighter 
in blondes and darker in brunettes, the fundus presents a 
uniformly pinkish-yellow appearance, broken by the red- 
dish walls of the retinal arteries and veins, as they course 
over the retina in their exit and entrance in the optic nerve. 
The head of this structure is plainly visible, and presents 
itself as a small pinkish-white plaque, surrounded by a fine 
layer of pigment, which defines its edges from the surround- 
ing tissues. Xot far from the outer side of the nerve is 
the macula lutea, the most highly sensitized of all the parts 
of the retina, as it is upon this point that the central rays 
of light are converged. This important area is darker than 
the rest of the fundus, with a small bright spot in the centre 
called the fovea centralis. The variations from this healthy 
or physiological appearance of the fundus will be discussed 
in future chapters (Plate II, A and B) , 



CHAPTER III 

DEFECTS OR ANOMALIES OF REFRACTION 
AND THEIR CORRECTION 

SPECTACLES AND EYE-GLASSES 

As we have already seen, by the refraction of the nor- 
mal eye is meant the power the eye has of so acting upon 
the rays of light passing through the pupil that they are 
converged upon the retina. This is accomplished without 
eiFort or strain unless the power of the eye be taxed unduly. 
If, however, the build of the eye departs from the normal 
and its length is too short, as in the far-sighted eye, or too 
long, as in the near-sighted eye, clear vision is attained only 
by the exercise of strain or, as is the case in the near-sighted 
eye, by the aid of suitable glasses. 

Far-sightedness or Hypermetropia. — As may be 
seen by the diagram of a far-sighted eye (see Fig. 11), by 
reason of its deformity in length, entering parallel rays of 
light are not brought to a focus upon the retina, but unite 
some distance behind this membrane, this distance varying 
in amount with the length of the eye. Under such conditions 
clear vision is impossible. Happily, however, the eye is 
equipped with a mechanism which can readily correct this 
lack of refraction power and bring parallel rays of light to 
a shorter focus. This consists in increasing the refractive 
power of the crystalline lens by a spontaneous and volun- 
tary contraction of the ciliary muscle. In the normal eye 
the ciliary muscle is relaxed in distant vision, coming into 
action only when the eye focusses on a near object. In 
hypermetropia, however, sharp vision both for far and near 



DEFECTS OR ANOMALIES OF REFRACTION 27 

is only obtained through the aid of this important muscle, 
the degree of its contraction varying with the demand 
placed upon it, being greater the higher the degree of the 
far-sightedness and vice versa. 

This constant and unnatural demand upon the ciliary 
muscle, however, after a time is associated with evil con- 
sequences. In the young and vigorous the strain may be 
maintained for a long time without perceptible disadvan- 
tage, but in older subjects and those with impaired health, 
symptoms of fatigue of the ciliary muscle soon manifest 
themselves. These may express themselves in a variety of 
ways. In the first place, vision is not always clear, and this 
is particularly true of near vision. As we have seen on 
page 18, the perception of near objects is accomplished by 
the act of accommodation, v/hich consists in increasing the 
convexity of the crystalline lens by action of the ciliary 
muscle. Precisely the same mechanism is employed to 
overcome far-sightedness. When a far-sighted eye is called 
upon to accommodate for a near object, it has already ex- 
pended some of its power in overcoming its deficiency in 
length, and has lost considerable of its reserve accommoda- 
tive power. If the degree of far-sightedness is consider- 
able, therefore, or if the ciliary muscle has been weakened 
by a general state of muscular weakness, or, what is more 
important, if the lens has become harder from age and 
requires greater muscular contractability to affect its 
curvature, the perception of the eye for small ob j ects close 
at hand is much impaired, if not entirely lost. In moder- 
ate amount of far-sightedness, the strain on the ciliary 
muscles evidences itself by blurring of the type, for ex- 
ample, in reading, or a running-together of the stitches in 
sewing. In far-sightedness of high degree, even distant 



28 HYGIENE OF THE EYE 

vision may be impaired, the ciliary muscles being unequal 
to the strain of maintaining a constantly increased curva- 
ture of the lens for a protracted period. 

The activity of the ciliary muscle may also give rise to 
deleterious changes within the eye itself and the structures 
neighboring upon the globe. Continuous contraction of 
the ciliary muscle means an increase in the amount of 
blood within the muscle, to provide for its nourishment and 
maintenance. Contiguous structures, such as the choroid, 
retina, and optic nerve, also participate in this state of 
hypersemia, as it is called, and mild inflammatory changes 
are evoked, which give rise to symptoms emanating from 

A 
L 




Fig. 17. — Correction of hypermetropia bj- a convex lens. The eye is drawn of the natural 
size of a hj-perme tropic eye having an axial length of 21 mm. 

these tissues. Sensitiveness to light is complained of and 
the eyes become red and irritable; the conjunctiva and 
lids also sharing in the hypersemia, become inflamed also. 
JNIuscular activity necessitates the expenditure of ner- 
vous force also, and in consequence of the maintenance of 
the ciliary muscles in a state of continuous action, constant 
impulses must be sent from the brain for their innervation. 
Headache is originated and a series of nervous reflexes, 
which will be treated of in a subsequent chapter. Owing 
to the strain placed upon the muscles rotating the eyeballs 
inward, far-sightedness of high degree frequently gives 
rise to strabismus or cross-eye (see p. 52) . 



DEFECTS OF ANOMALIES OF REFRACTION 29 

The optical principles involved in the correction of far- 
sightedness are extremely simple, consisting merely in the 
determination of the far-sightedness, and the removal of 
the strain upon the ciliary muscles, by the superposition 
before the eye of a convex lens equal in amount with the 
refraction error (Fig. 17). This auxiliary lens at once 
removes the necessity for the increased curvature of the 
crystalline lens, and the ciliary muscle is again placed at 
rest, in so far at least as distant vision is concerned. 

Although the optic principles involved are simple, the 
prescribing of glasses in far-sightedness is often a matter 
of some complexity. In the first place, the degree of far- 
sightedness is not always the same in all the meridians of 
the eye, and the complication of astigmatism may be pres- 
ent. Secondly, there is some dispute regarding the proper 
manner of determining the amount of hypermetropia pres- 
ent. ]Most cautious and thorough ophthalmologists claim 
that this can only be accomplished, in subjects under 40 
years of age, by the local use of some drug which will sus- 
pend the action of the ciliary muscle. Others, chiefly opti- 
cians and optometrists, who are not permitted by law to 
employ any form of drugs in their examinations of the 
eye, assert that this is unnecessary and that accurately pre- 
scribed lenses may be given without putting the ciliary 
muscles at rest. 

Were the eye but a camera, a fixed and stable optical ap- 
paratus, and the regulation of its focussing apparatus un- 
associated with muscle spasm, it would be a simple matter 
to determine the degree of far-sightedness present by ascer- 
taining the strongest convex lens by means of which the 
sharpest degree of distant visual acuitj^ was attained. After 
40 years of age, the eye approaches in a manner the sta- 



30 HYGIENE OF THE EYE 

bility of such a fixed optical instrument, for, as we have 
seen, after that age the lens becomes so hard that the 
ciliary muscle has but little power to change its shape. 
In subjects over 40 years of age, therefore, satisfactory 
results may usually be attained in this manner. In younger 
persons, however, an active muscle, operating upon a flexi- 
ble lens, has to be taken into consideration, as well as the 
deleterious effects which may have arisen in the eye in 
consequence of the vicious use of that muscle. It would 
be beyond the scope of this work to enter into a full dis- 
cussion of all the optical principles involved in refraction, 
and to attempt an explanation of the various changes which 
occur in the ciliary muscle in errors of refraction. It may 
be stated, however, that in far-sightedness, in consequence 
of the extra work placed upon it, the ciliary muscle becomes 
excessively strong, and hypertrophies. Its contractions 
frequently become spasmodic and render all attempts to 
estimate the degree of the refraction error extremely diffi- 
cult. Before the exact amount of far-sightedness present 
in any eye under 40 years of age can be accurately deter- 
mined, therefore, some means must be used to eliminate the 
action of this muscle and to prevent its contractions modi- 
fying the results of the examination. Fortunately, such 
means are afforded by a class of drugs termed " mydri- 
atics " or, better, " cycloplegics," drugs which have the 
power of dilating the pupil and temporarily suspending 
the power of the ciliary muscle. 

These drugs are of two classes, the quick-acting, of 
which homatropin is the type, and atropine, a derivative of 
belladonna, whose effects are much more lasting. Gen- 
erally speaking, atropine is the ideal drug for refraction 
purposes, for it not only assures a complete abeyance for a 



DEFECTS OR ANOMALIES OF REFRACTION 31 

time of all action of the ciliary muscle, but it secm-es for 
the tissues of the eye a needful rest, which is often most 
essential after the eye tissues have been long subjected to 
the effects of strain. As we shall see in the description of 
near-sightedness, a large proportion of near-sighted eyes 
develop from uncorrected far-sighted eyes, whose tissues 
have been strained and softened by the unnatural strain 
placed upon them. In such eyes, the prolonged use of 
atropine is invaluable, the softening and stretching proc- 
ess being entirely arrested by it. In children, the coats of 
whose eyes are weak and yielding and whose ciliary muscles 
are strong and active, atropine is the drug of choice. 

The objections to atropine are the length of time neces- 
sary to complete the test, the effects of the drug lasting 
for about ten days to two weeks, and the constitutional 
symptoms which appear at times after even one instillation 
of the drops. The first objection is readily met by a con- 
sideration of the advantages to be derived from this short 
interruption of work or pleasure. Unless the condition of 
the eyes to be refracted shows signs of urgency, the refrac- 
tion test under atropine, in the case of school children, can 
usually be postponed until the holidays, and in other cases 
few employers will grudge an employee sufficient time to 
gain a greater efficiency in his work by obtaining proper 
ocular treatment. 

The constitutional symptoms which occasionally ap- 
pear, though made much of by optometrists and others 
who are prevented by law from employing drugs of any 
kind in their refraction work, are usually very slight, and 
pass away rapidly after the cessation of the treatment. A 
diminished dosage in children and refraining from the use 
of atropine in extremely warm weather are usually the 



32 HYGIENE OF THE EYE 

only safeguards necessary to be observed. Another objec- 
tion is sometimes made that atropine may precipitate an 
attack of glaucoma. In elderly persons predisposed to 
glaucoma, such accidents have been known to occur, but 
may easily be prevented by the careful systematic examina- 
tion of the eyes which should precede the instillation of 
drugs of any kind for refraction or other purposes. Most 
eye surgeons of experience have treated thousands of cases 
without having this unfortunate accident happen. 

Near-sightedkess^ Myopia. — Diametrically opposite 
to the far-sighted eye is the near-sighted or myopic eye, for 
in this anomaly of refraction the eyeball is too long, and 
rays of light coming from a distance are brought to a focus 
in front of the retina. We have seen how the far-sighted 
eye may secure clear distant vision by a contraction of the 
ciliary muscle, but in myopia such an increase in the focus- 
sing power of the eye only accentuates the difficulty, nor 
is there any other mechanism possessed by the near-sighted 
eye which enables it to overcome its visual deficiency, so 
that the myope is dependent entirely upon the artificial aid 
of lenses to see distant objects clearly. By squinting the 
lids, and excluding some of the marginal rays entering the 
eye, the myope is enabled to see somewhat clearer, but the 
degree of visual clearness obtained by this means is verj^ 
slight. 

As has been stated in an earlier chapter, the shape of 
the skull frequently determines the conformation of the 
orbit, which, in its turn, moulds the form of the eyeball. 
Myopia, therefore, occurs most commonly in races like the 
Teutonic, whose skulls are long in the anteroposterior di- 
ameter, and is but rarely met with in the negro and Indian, 
where the converse is the rule. 



DEFECTS OR ANOMALIES OF REFRACTION 33 

Owing probably to the transmission of the shape of the 
skull favoring the development of myopia, this error of 
refraction is often hereditary, being transmitted through 
several generations and often occurring among many mem- 
bers of the same family. Myopia is but rarely congenital, 
generally developing from the eighth to the tenth year, its 
appearance at that time in eyes formerly emmetropic or 
far-sighted being traceable to (a) the hereditary influence 
just referred to, (b) unusual strain upon the eyes, either 
from overuse or use under improper conditions of lighting, 
etc., (c) ill health, or (d) to some irregularity in the corneal 
curvature, or haze of the refracting surface of the eyes, 
which impairs, though but slightly, the proper focussing of 
the rays of light upon the retina. 

As we have seen, the myopic eye is too long an eye. 
Emmetropic and hypermetropic eyes become myopic in 
consequence of a stretching in their coats, a process which 
is never physiological and is accompanied by more or less 
danger to the ocular structures. Myopia exhibits also a 
marked tendency to be progressive, the degree of the near- 
sightedness tending to increase year by year until the proc- 
ess is arrested. This arrest in the stretching process usu- 
ally happens in healthy subjects whose eyes are not 
subject to too great strain, between the ages of 20 and 30 
years, but in some cases it continues through life, and, being 
always attended with evil consequences to the integrity of 
the eyeball, may cause such damage that the eye no longer 
is possessed of useful vision. Indeed, in some cases the 
damage suffered is so great that the removal of the eye 
is necessitated for the relief of pain and other inflammatory 
symptoms. To show the effect of school life upon the 
eyes the following percentages of Cohn, a German oph- 



34 HYGIENE OF THE EYE 

thalmologist, who made extensive researches some 50 years 
ago, with a view to determining the incidence of myopia in 
Germany, are of interest : 

Percentage of myopia 

Five village schools 1.4 

Twenty elementary schools 6.7 

Two higher girls' schools 7.7 

Two intermediate schools 10.3 

Two real-schulen 19.7 

Two gymnasiums. 26.2 

Among the students of the university, Cohn found the 
percentage of myopic eyes had advanced to 59.5. His con- 
clusions demonstrated that not only does the number of 
short-sighted pupils increase from the lowest to the highest 
schools, but that the increase is in direct proportion to the 
length of time devoted to the strain of school life. In 1885, 
Risley and Randall compiled a similar group of statistics 
based upon the examination of a large number of eyes by 
competent American oculists, and found an analogous, 
though somewhat lower continuous progression in the per- 
centage of myopia in American schools. In 1907, the 
author, in conjunction with Dr. R. Tait McKenzie, Di- 
rector of the Department, in his capacity as Ophthalmol- 
ogist to the Department of Physical Education in the 
University of Pennsylvania, made an analytical study of 
the eyes of 883 students in the various departments of that 
institution. In the comparison which was made to ascer- 
tain the influence of age and study on the refraction, it was 
found that among 633 students in the two lower classes, 
87.25 per cent, were hypermetropic and 12.75 per cent, 
were myopic, while of 261 students in the upper classes, 
80.25 per cent, were hypermetropic and 19.75 per cent. 



DEFECTS OR ANOMALIES OF REFRACTION 35 

were myopic. The average of all the scholars examined 
was 21.4 years, and the statistics showed an increase of 
about 2.5 per cent, of myopia for each year during the 
four years of college life. Five per cent, more of myopia 
was found in the professional departments in scholars of a 
similar age than in the college department, this being 
doubtless accounted for by the fact that most of the scholars 
in the college come from private or city schools, where the 
eyes are properly protected, while the scholars in the pro- 
fessional schools come from rural communities, where ac- 
curate refraction is impossible and the care of the eyes 
neglected. 

In addition to the professional classes, many artisans 
whose work entails prolonged and taxing eye work become 
myopic. Hebrews, owing perhaps to racial peculiarities of 
skull, are often near-sighted, frequently to the highest 
degree. 

On account of their poor vision, myopes without glasses 
are greatly handicapped in many waj^s. Thus individuals 
with this build of eyes often manifest a strong distaste 
for all outdoor sports in which sharp vision is a requisite, 
and acquire a marked predilection for indoor occupations, 
painting, books, etc., a taste which is especially unfortunate, 
as prolonged near work of all kinds only aggravates their 
difficulty and adds to their ocular deficiency. In conse- 
quence of their inability to note the expression of those with 
whom they come in contact, the myope often develops an 
abstracted and even a stupid expression of countenance, 
and exhibits a degree of shyness not so frequently seen in 
those with normal vision. Although there may be but 
slight strain placed upon their ciliary muscles, uncorrected 
near-sightedness frequently gives rise to headaches and the 



36 



HYGIENE OF THE EYE 



other symptoms enumerated elsewhere as the consequence 
of eye-strain. 

The diagnosis of near-sightedness, when present to an 
appreciable degree, may be suspected, when in addition to 
poor distant vision the subject is able to read the finest type 
with the greatest ease, provided the book or magazine is 
brought close enough to the eyes (Fig. 18). 




Fig IS.i. — This near-siiilited boy is trying to read without glasses and is in danger of 
serious trouble later if neglected. Properly fitted glasses would add to the boy's comfort and 
appearance, as well aa provide insurance for his future. 

Fig. ISB. — When glasses are properly fitted, comfort and safetj' are secured. 

Upon ophthalmoscopic examination, the observer will 
note certain characteristic changes in the fundus dependent 
in degree and extent to the amount of stretching which the 
eye has undergone. Most constant of these is a crescentric 
area of partial and complete atrophy of the choroidal and 
retinal elements to the outer side of the optic nerve, which 



DEFECTS OR ANOMALIES OF REFRACTION 37 

in high grades of myopia may extend to and even involve 
the area of most distinct vision. 

By reason of the lessened demand upon accommodation, 
correlated convergent efforts are also diminished and 
myopic eyes frequently become divergent. 

The eyeball being elongated unduly, the vitreous is no 
longer adequate to fill the space it occupies under normal 
conditions, and becoming disorganized by the attendant 
choroidal disease, becomes fluid and more or less filled with 
opacities, which float to and fro with the movements of the 
eyes and occasion the motes or muscce volitantes, which be- 
come a source of great annoyance. Finally, as a result of the 
lack of support given it by the altered vitreous and weak- 
ened by the sublying choroidal disease, the retina, in re- 
sponse to some slight tap upon the eye or to some jar of the 
body, floats loose from its attachments and encroaches upon 
the space normally occupied by the vitreous. Loss of sight 
in the area occupied by the detachment follows, and unless 
reparative measures be properly applied, and. unfor- 
tunately in many cases, even in spite of the most prompt 
and best medical care, total blindness may ensue. 

From the foregoing it must be evident that myopia is 
a pathological condition of the eyes which demands the 
most careful consideration, not only of the oculist but the 
layman as well. There is a more or less general impres- 
sion that near-sighted eyes are stronger than others, and 
on account of ease in reading, etc., myopes not infrequently 
transgress the laws of prudence and prolong the use of the 
eyes at close work beyond reason. Often it would appear 
as though the tax was without deleterious consequences, 
and the eyes apparently tolerate years of abuse without 
giving signs of failing. By middle life, however, the 



38 HYGIENE OF THE EYE 

changes wrought by misuse rarely fail to manifest them- 
selves, and the unfortunates who have persisted in the mal- 
treatment of their eyes are now forced to be sparing of 
their use, at a time when physical limitations curtail the 
enjoyment of participation in an active outdoor life and 
necessitate sedentary habits. The prevention and correc- 
tion of myopia, therefore, is a problem of great sociologi- 
cal as well as medical significance, and it must be a matter 
of gratification to their countrymen that American oculists 
for many years have devoted much study and effort to 
its solution. 

The prevention of myopia includes a steadfast and 
intelligent observance of all the details enumerated in 
Chapter VI, but especial emphasis must be laid upon the 
necessity for an early examination of all children's eyes, 
with a view to ascertaining the state of the refraction, and 
for the prompt and efficient correction of any errors which 
may be found. The laity must disabuse its mind that the 
wearing of glasses has any weakening effect upon the eyes, 
and must appreciate that the most potent factor to pre- 
vent the progress of ocular deficiencies is properly adjusted 
glasses. One of the most pathetic, and unfortunately a not 
uncommon experience of the oculist, is to have children 
with eyes well advanced in myopia brought for consulta- 
tion by parents who have deferred the visit in the hope that 
the longer they postponed the examination, the more chance 
there will be of the apparent error of diminished distant 
vision being outgrown. Errors of refraction are never out- 
grown, but, on the contrary, if they are permitted to go 
uncorrected, steadily increase, often insidiously, with re- 
markable rapidity. 

Parallel rays of light falling upon the cornea of a near- 



DEFECTS OR ANOMALIES OF REFRACTION 30 

sighted eye are brought to a focus in front of the retina. 
Myopia is corrected, therefore, by the superposition of a 
concave lens before the eye, such lenses having the property 
of causing the divergence of rays of light passing through 
them, and the weakest concave glass which enables the 
near-sighted eye to see sharpest is the measure of the degree 
of myopia present (Fig. 19). 

Other important factors, however, must be taken into 
consideration before finally determining the lens which 
shall be prescribed, for, as in hypermetropia, the selection 
of the correcting glasses demands considerable skill and 
judgment. Astigmatism may be present, and, as in hyper- 



FiG. 19. — Correction of myopia by a concave lens. The eye is drawn of the natural size of a 
myopic eye having an axial length of 27 mm. 

metropia, there may be more or less associated spasm of the 
cihary muscle, which may mask the true amount of myopia 
present by adding to it, in consequence of the increased 
thickness of the lens, and the earlier refraction of the rays 
which is thereby occasioned. The necessity for the em- 
ployment of a cycloplegic in the measurement of myopic 
eyes is of even greater importance, therefore, than in test- 
ing far-sighted eyes, for if too strong concave glasses are 
prescribed, the ciliary muscle will be excited to still greater 
action, and, thereby increasing the intra-ocular congestion 
and softening the coats of the eye, cause actual increase in 
the myopia. Atropine, therefore, should be the drug of 



40 HYGIENE OF THE EYE 

choice in all tests of myopic eyes in childhood and adoles- 
cence, the drug having the two-fold advantage of not only 
enabling the examiner to determine with accuracy the de- 
gree of myopia present, but also of putting the coats of the 
eye at rest, of diminishing the congestion of the eye, and 
allowing the eyeball to recover its natural vigor and tone. 
Instead of " drops," so-called, being harmful, in this class 
of cases they are, on the contrary, actually priceless, and 
often check the progress of a rapidly increasing near- 
sightedness. 

As the tendency of myopia is to increase, examinations 
should be made annually, until a period of comparative 
non-progressiveness has been reached. After that, exami- 
nations every two or three years are ordinarily sufficient. 

While under certain conditions in older subjects cor- 
recting glasses need be worn only to secure sharp distant 
vision, in myopic children and adolescents it is imperative 
that they be worn constantly, to remove all strain in near 
as well as in distant use of the eyes. As must be apparent 
from what has already been said about the progressive 
nature of .myopia and the yielding tissues of the child's 
eye, no prejudice about the wearing of glasses by children 
for cosmetic or other reasons should be permitted to out- 
weigh the great benefit to be derived from this most potent 
and accurate manner of relieving ocular strain. After the 
period of adolescence has passed and the danger of the 
myopia increasing is lessened, it is oftentimes feasible, 
provided the degree of the myopia is not too great, and 
the coats of the eye healthy, to remove the glasses for con- 
stant use and to resort to them only at close work, or at 
such times at it may be desirable to obtain full distant 
vision. Ordinarilv the same lenses mav be worn for both 



DEFECTS OR ANOMALIES OF REFRACTION 41 

far and near use; in certain cases, however, it is desirable 
to prescribe a weaker pair of lenses for close work. If the 
near-sightedness is attended w^ith marked w^eakness of the 
ocular muscles, prisms are often of value, and may be 
ground into the concave lenses correcting the myopia. In 
some cases, division of one or more of the eye muscles is 
desirable. ]Myopia of very high degree is sometimes 
lessened by the removal of the crystalline lens by operation. 
This procedure, however, is not without danger, and is 
only to be recommended in extreme cases. 

As myopia increases with the use of the eyes, parents 
and those engaged in the education of the j^oung should 
realize the dangers of excessive reading and the prolonged 
use of the eyes in all kinds of fine near work. In Chapter 
VI detailed instruction regarding this and other phases of 
the care of the eyes will be given in full, as well as an ac- 
count of the method which has been suggested for the 
education of high myopes. 

As near-sighted individuals can at all times, unless 
there be considerable astigmatism present, see near objects 
clearly, they possess the advantage over those who are 
emmetropic or hypermetropic of being able to read, etc., in 
advanced life, after the presbyopic period has arrived, with- 
out glasses. It is for this reason that the impression has 
spread that near-sighted eyes grow stronger and vision im- 
proves with age. This is not true, however, as the degi-ee of 
true myopia never lessens, and proper concave glasses must 
be worn at all times to obtain clear distant vision. 

The so-called " second sight," or ability acquired by 
some individuals to read late in life without the aid of 
glasses, is really symptomatic of cataract, and is due to 
swelling and increase in the refractive power of the lens, 



42 HYGIENE OF THE EYE 

which is one of the stages of this form of ocular disease. 
Astigmatism. — As has been defined elsewhere, astig- 
matism is an error of refraction, dependent not upon 
the shape of the entire eyeball, but upon an irregularity in 
curvature in one of its refracting surfaces, usually the cor- 
nea. If the curvatures of the two principal meridians of 
the cornea are at right angles to one another, the astig- 
matism present is said to be regular; irregular when the 
unequal curvatures bear no definite relation to each other. 
The latter form of astigmatism arises usually from injury 
or disease of the cornea, which has affected its transparency 
as well as its refracting curvatures. Irregularities in the 
structure of the lens produce a slight amount of this form 
of astigmatism in all eyes, which accounts for the irradia- 
tion about the stars and for the rays of light which shoot 
out from street lamps and other distant points of light. In 
regular astigmatism, if the inequalities between the two 
meridians of the cornea be but slight, vision may be but 
little interfered with, but if the degree be at all marked, the 
foci of the two sets of rays are so far apart that only a 
blurred image of surrounding objects is obtained. Astig- 
matism may be either hypermetropic or myopic, according 
as one meridian is more or less curved than the other 
meridian ; mixed when one meridian is myopic and the other 
hypermetropic; or compound, when both have different 
degrees of myopia or hypermetropia. A popular demon- 
stration of astigmatism is to draw a line around an egg 
through the ends and another around the middle, at right 
angles to the first ; it will be evident that these lines have a 
very different curvature, and that if the egg were made of 
glass it could not form a sharp focus, as a glass sphere 
does — it would be astigmatic. 



DEFECTS OR ANOMALIES OF REFRACTION 



43 



The symptoms evoked by astigmatism, in consequence 
of the strain placed upon the ciliary muscle in its efforts 
to focus the rays of different lengths, are usually very pro- 




TiG. 20 A. — Figures on blackboard sharp and clear. This is the way they look to the child with 
abnormal eyes after he has been properly fitted with glasses. 




Fig. 20B. — Blurred picture of schoolroom, showing how room looks to a child with astig- 
matic eyes. 

nounced, and this form of ametropia may be suspected 
when, in reading, the letters are confused and seem to run 
together (Fig. 20), and when the head is inclined to one 



44 HYGIENE OF THE EYE 

side in an eiFort to obtain sharper vision. The hds are 
frequently contracted in an effort to shut out marginal 
rays. Headache is common and other forms of reflex ner- 
vous disturbances are present. If an astigmatic person 
close one eye and gaze fixedly at a so-called astigmatic 
dial (Fig. 21) placed 5 metres from the eyes, he will note 
that certain rays appear much darker and more distinct 
than others. This device often enables the ophthalmologist 
to determine the axis of the corneal curvature, and is of 
service in the final prescription for glasses. Astigmatic 
persons usually attribute their poor vision to near-sighted- 
ness. No form of spherical surface, be it convex or con- 




FiG. 21. — Astigmatic dial. 



cave, will, however, improve vision, for what is needed in 
simple astigmatism is a glass which will correct one 
meridian without affecting the other, and in compound or 
mixed astigmatism, a glass with two curved surfaces, one 
adapted to each meridian. A section of a C3dindrical glass 
supplies the want. Fig. 22 represents such a glass; the 
rays of light ab passing through its axis, meet with no 
curve and are unrefracted, while those at right angles cd 
meet with a strong convex surface and are brought to a 
focus. Such cylindrical lenses are cut in the form ordinarily 
used in glasses and placed in the direction corresponding 
to the curvature of the astigmatism. They may also be 



DEFECTS OR ANOMALIES OF REFRACTION 45 

incorporated with spherical lenses in the correction of cases 
of compound astigmatism, i.e,^ astigmatism associated with 
far- or near-sightedness. 

The correction of astigmatism calls for the same care 
as has already been outlined in the discussion of the treat- 
ment of far- and near-sightedness. In subjects under 40 
years of age, some form of cycloplegic is absolutely essen- 
tial to determine the amount and axis of the astigmatism, 
for the compensatory action of the ciliary muscle often ob- 
scures the amount of the astigmatism and shifts its axis. 
A faulty correction of astigmatism is almost as harmful as 
no correction, and no glasses should be prescribed until the 





d 




l.----- 




"="t^ 


I_^_ 


■I 


_TI_) 


li _■ 


-•-— ^ 


T::i / 


[/----- 


/ 


r.-.-jr.--.-.-:^-—-.:: J 



c 

Fig. 22. — Cylindrical lens. 



examiner has been satisfied, by several examinations in 
which he has been aided by the various tests which have 
been devised by ophthalmologists for the detection of this 
error of refraction, that he has determined with absolute 
accuracy both its amount and axis. 

AxTiMETROPiA ; ANISOMETROPIA. — Thcsc tcrms are 
used synonymously to define different degrees of refrac- 
tion in the eyes of the same individual. Thus one eye may 
be near-sighted and the other far-sighted or astigmatic, and 
often considerable degrees of muscular imbalance accom- 
pany the condition, with attendant difficulty in obtaining 
comfortable simultaneous use of the two eyes. If one eye 
is very near-sighted and the other almost of normal build, 



46 HYGIENE OF THE EYE 

it is at times desirable not to attempt the correction of the 
myopic eye, and refract one eye only. 

Presbyopia. — ^When considering the subject of accom- 
modation, presbyopia was defined as the loss in the power 
of accommodation due to advancing years, and was found 
to be dependent upon an increasing hardness in the crys- 
talline lens. This hardening process is entirely physiologi- 
cal and there is nothing abnormal for one who has previ- 
ously suiFered from no ocular limitations whatsoever to be 
compelled to resort to glasses to see small near objects 
clearly at some time between the ages of 40 and 50 years. 
The elongation of the eye by myopia and the added refrac- 
tion strength acquired in this way may postpone the neces- 
sity of the near-sighted wearing glasses to correct pres- 
byopia until several years beyond the normal period, and if 
the degree of the myopia be considerable, persons with this 
error of refraction may be able to read the finest type with- 
out glasses throughout life — a slight advantage to counter- 
balance the limitations of far-sight always possessed by 
myopes. On the other hand, hypermetropia, by the addi- 
tional strain it entails upon the muscles of accommodation, 
precipitates presbyopia. If, in the years preceding the 
advent of the period at which presbyopia usually manifests 
itself, the eyes have been of normal build and there is no 
astigmatism present, the prescribing of lenses to improve 
the perception of near objects is a simple matter and may 
in many instances be left in safety to the optician and 
optometrist, always with the recognition, however, that in 
so doing the opportunity of submitting the eyes to a thor- 
ough examination with a view to determining possible dis- 
ease of the eyes or general system is not taken advantage 
of, as would be the case were the test made at the hands of 



DEFECTS OR ANOMALIES OF REFRACTION 47 

a competent medical adviser. If astigmatism or other as- 
sociated anomaly of refraction is present, or imbalance of 
the ocular muscles, the test becomes more complicated and 
an expert examination is essential. Uncorrected pres- 
byopia calls for a convex spherical glass for its correction, 
thereby supplementing the refractive power lost by the 
rigidity of the crystalline lens. The strength of the lens 
must be increased every year or two, to supplement the 
increasing hardness of the lens, until the age of 55 or 60 
years has been reached, after which time no increase in the 
lens strength for purely presbyopic purposes is necessary, 
although later swelling in the lens from cataractous change, 
or from certain structural changes in the eye, may neces- 
sitate additional tests and other lenses. 

Spectacles and Eye-glasses 
Correcting glasses may be worn either in the form of 
eye-glasses or spectacles. Monocles, or single eye-glasses, 
so popular among the military and others of the upper 
classes abroad, have fortunately never been popular in our 
own country, as they throw undue strain upon the eye in 
use and can only be regarded as a makeshift and never as 
a lens capable of correcting a refraction error. 

In the event that lenses must be worn constantly, spec- 
tacles will under nearly all circumstances be found more 
useful than eye-glasses. Cosmetically, however, the latter 
are to be preferred, and unless there is some structural 
peculiarity of the nose which prevents the proper adjust- 
ment of eye-glasses, or unusually heavy lenses, or lenses 
containing cjdinders for the correction of astigmatism of 
such high degree that the slightest deviation in their axis 
is attended with distress, adults may safely wear this form 



48 HYGIENE OF THE EYE 

of adjustment. On account of the liability to displacement 
and accident in play or romping, children should always be 
fitted with spectacles and these should be provided with 
stout rims for additional strength and to prevent injury to 
the eye from the shattering of the lenses in case of accident. 

The choice between spectacles and eye-glasses is, how- 
ever, so far as adults are concerned, of but minor impor- 
tance in comparison with the adjustment of the lenses be- 
fore the eyes. The average person considers that the ocu- 
list has finished his work when after the test he has been 
given the formula and has obtained the glasses from the 
optician. Every oculist, however, who is at all alive to 
the welfare of his patients and his own reputation will 
insist that he be given an opportunity to ascertain that the 
lenses have been ground according to his prescription and 
to see the lenses which he has prescribed in position before 
the eyes. Many a carefully selected formula has failed to 
give the relief expected by reason of a careless adjustment. 
]Vot only must the centres of the lenses correspond to the 
ocular centres, but the distance of the lenses from the eyes 
must be proper and no greater space permitted between 
the two than is sufficient to prevent the tips of the eye- 
lashes from touching the glass. 

Lenses must be worn at a correct angle, i.e., somewhat 
slanting, so that the top of the lenses is somewhat farther 
away from the eyes than the lower portion. The accom- 
panying photographs with their legends illustrate how 
glasses should and should not be worn (Fig. 23). 

When lenses of different strength must be worn for 
far and near use, they may often be combined in bifocal 
form ; that is to say, a reading segment may be fitted into a 
space cut from the lower half of the distance lens to admit 



DEFECTS OR ANOMALIES OF REFRACTION 



49 




Fig. 23. — A, lenses too low and wide; B, lenses correctly positioned; C, lenses incorrectly 
inclined; D, lenses correctly inclined; E, lenses out of horizontal alignment; F, lenses correctly 
positioned. 



50 HYGIENE OF THE EYE 

it. Recent optical improvements permit of the reading 
glass being separately ground as an insert on the distance 
lens, or cemented or fused to it. This latter is known as the 
Kryptok lens, and the reading portion is invisible unless 
examined under certain aspects. While a great conveni- 
ence, especially to elderly people, in obviating a change of 
glasses when adjusting the eye for various distances, many 
have difficulty in accustoming themselves to them, espe- 
cially in walking, on account of the blur thrown over ob- 
jects directly in front of the feet. A precise adjustment of 
the lenses, however, and some practice will usually over- 
come this slight disadvantage. 

As a substitute for the bifocal, so-called " fronts " are 
sometimes prescribed, ix.^ the necessary strength of lens 
for reading is mounted in a rigid eye-glass or spectacle 
frame provided with hooks at each end, and slipped over 
the distance correction at will. Ladies frequently have 
lenses with proper reading strength mounted in a lorgnette, 
which they hold superposed over their distance correction. 

When glasses are worn for near use alone, the lenses 
should be inclined forward and set about 5 mm. lower than 
those for distance, to conform with the usual downward 
fixation of the eye at close work. At times it is convenient 
to cut away the upper half of the reading glasses, so that 
the eyes obtain a clear view of distant objects over the top. 
As few eyes are not benefitted by a correcting glass for 
distance, the ordinary bifocal form is to be preferred. 

Lenses should be amply large, though the present mode 
of extraordinarily large glasses is not to be commended, 
except for their employment in shooting, billiards, etc. 

It is frequently of advantage to have the surface of the 
lens curved instead of being flat, the advantage of these 



DEFECTS OR ANOMALIES OF REFRACTION 51 

periscopic or toric lenses being that the curvature of the 
glass approximately corresponds to the curve of rotation 
of the movements of the eyeball, and the refraction is the 
same through all parts of the lens, whereas in a flat lens, 
and especially those of high power, the eye sees clearly 
only through the optical centre of the lens, necessitating a 
turning of the wearer's head in observing all side objects. 

Wearers of glasses should make it a point to visit the 
optician from whom they obtain their lenses at regular 
intervals, in order to rectify any errors in adjustment. Such 
service is usually rendered gratis and insures that the lenses 
are properly centred. 

In recent years the prescribing of colored or tinted 
glasses has had quite a vogue, such lenses being ordered with 
the idea of preventing certain harmful light rays from en- 
tering the eye. There can be no question, however, but that 
this has been overdone and that neither daylight nor ordi- 
nary sources of artificial light contain radiations either in 
kind or degree which are injurious to the healthy eye. The 
comfort derived from amethyst, amber, and other tinted 
glasses is usually psychic and is imparted largely by the 
suggestion of the oculist or optician prescribing them. 
While healthy eyes under ordinary conditions require no 
interference with the rays coming from ordinary light 
sources, diseased eyes do. Under such circumstances, those 
of neutral shade, ix,, those known technically as London 
Smoke, are to be preferred. Such lenses merely diminish 
the amount of light entering the eye without interfering 
with spectral or heat rays. The proper kinds of lenses to 
protect the eyes from the deleterious action of an excessive 
amount of light and heat rays has been discussed elsewhere. 



CHAPTER IV 
STRABISMUS, CROSS-EYE OR SQUINT 

If for any reason the harmonious action of the muscles 
moving the eyes is disturbed, the normal parallelism of the 
axes is interfered with and the eyes become crossed. This 
may occur either as a result of paralysis of one or more of 
the eye muscles from injury or serious systemic disease; it 
may originate, as we have seen, from anomalies of refrac- 
tion, or it may be congenital, and the eyes crossed from 
birth. The character of the strabismus may be simple or 
mixed. That is to say, an eye may turn in or out, in rela- 
tion with its fellow, or this lateral deviation may be con- 
joined with a vertical one, depending upon the number 
of eye muscles affected. In paralytic squint, the deviation 
as a rule occurs more or less suddenly and double vision 
obtains. In strabismus from high degrees of farsighted- 
ness or from myopia, the development of the deformity is 
gradual and the perception of the image of the deviating 
eye is suppressed, and double vision is absent. It is also 
rarely present in congenital squint. 

Squint or Cross-eye Resulting from Errors of 
Refraction. — Under normal conditions, both eyes are di- 
rected upon the same point at the same time. In regard- 
ing near ob j ects, both eyes are strongly converged and held 
in this position of focus largely through the action of the 
internal rectus muscles, the two muscles chiefly concerned 
in rotating the eyes inward. Simultaneously with this 
strong convergent effort, to obtain a clear image of the 

52 



STRABISMUS, CROSS-EYE OR SQUINT 



53 



object at which the eyes are directed, there must be a strong 
contraction of the cihary muscle of each eye ( Fig. 24 ) . In 
eyes of normal build, this action between convergence and 
accommodation is equably adjusted and the balance is 
maintained without strain, but in high degrees of far-sight- 
edness, the harmonious action is disturbed by the super- 
added amount of activity required by the ciliary muscles, 
necessitated by the shortness of the globes. The centres in 




Fig. 24. — Showing an increase in the angle of convergence of the optic axis in consequence 
of an extreme rotation of one eye, L, inward. The angle i' is thus made larger than the angle 
i, obtained for the eye, R, which consequently received a clearer image of vision, object A, 
on its retina (Swanzy). 

the brain controlling accommodative effort must send addi- 
tional stimuli to the ciliary muscles, and the correlated 
centres of convergence similar impulses to the convergence 
muscles. In consequence the eyes are converged out of 
proportion to the impulse needed for the distance upon 
which they are focussed. Binocular vision is maintained 
therefore only at the expense of great muscular strain and 
is relinquished if any condition arises which increases the 
difficulty or facilitates its interruption. Poor vision in one 



54 HYGIENE OF THE E^E 

eye, either from astigmatism or disease, is an example of 
the former contingency and the accidental discovery by 
the subject that fixation with one eye while the other is 
temporarily thrown out of focus relieves the strain, typifies 
the latter. There are those who believe also that preter- 
naturally weak brain centres controlling the muscles of the 
eyes is also a controlling if not the chief factor in the causa- 
tion of squint. 

In consequence of the causes just related convergent 
strabismus or cross-eye usually develops in hypermetropic 
eyes at about the third year, at the age when near objects 
are seriously regarded and the child holds the eyes in con- 
vergence when playing with toys, or regarding picture 
books, etc. The appearance of the squint soon after ill- 
nesses of various kinds frequently occasions the assump- 
tion that the particular disease from which the child has 
suffered has determined the ocular deviation. This idea, 
however, is erroneous, such illnesses precipitating the squint 
only in so far as they occasion a lowering of the general 
vitality and weaken the tone of the ocular muscles and the 
centres which supply them. 

The correction of convergent squint consists in the es- 
tablishment of a normal relationship between convergence 
and accommodation. This is accomplished by the adjust- 
ment of spectacles containing convex spherical lenses of 
sufficient strength to correct the amount of far-sightedness 
present. If this be done shortly after the squint has mani- 
fested itself, its correction is immediate and the eyes are 
straight as long as the glasses are worn. If there be delay 
and the lenses are prescribed some months or years after 
the strabismus has appeared, the squint may still persist, 
and the cure of the condition by glasses alone be impossible. 



STRABISMUS, CROSS-EYE OR SQUINT 55 

The reason for this is two-fold. In the first place, in con- 
sequence of the long suppression of the mental images re- 
ceived from the squinting eye, a happy device of nature to 
avoid the double vision which would naturally follow the 
departure from parallelism of the visual axes, the vision 
in the squinting eye becomes progressively impaired, and 
even though the refraction error be corrected by proper 
glasses, the eye will not cooperate with its fellow unless 
something is done to break up the habit of non-participa- 
tion which it has acquired through disuse. Again, various 
contractions of the muscles occur, in consequence of faulty 
action, which prevent their properly cooperating with the 
muscles of the other eye, even after the normal bal- 
ance between convergence and accommodation has been 
restored. 

Squint, therefore, not only disfigures, but actually dis- 
ables, impairing the vision of the crossed eye. Too much 
emphasis cannot be laid, therefore, upon the importance of 
correcting squint early. There is an impression, confined 
not merely to the laity but shared also by many general 
practitioners as well, that squint is often outgrown and 
that it is well to wait until the child suffering with squint 
is more matured before its correction is attempted. While 
this is sometimes true of the purposeless movements which 
are observed in the eyes during the first year of life, any 
constant deviation which persists after this age should 
awaken suspicion and should lead to the consultation of a 
competent oculist. While it may seem an unnecessary dis- 
figurement to adjust spectacles to the eyes of a child two 
or three years of age, such action not only may insure 
straight eyes for life, but, what perhaps is more essential, 
may prevent the loss of sight in the deviating eye. 



56 HYGIENE OF THE EYE 

In some cases, glasses need not be given at such an 
early age, but the knowledge possessed by eye specialists 
should be spread wide that if efforts are not made to cor- 
rect such eyes and develop the vision in the squinting eye 
before 6 years of age, but little can be done to restore sight 
in the deviating eye, even though the eyes be straightened 
by glasses or operative procedures. Ophthalmologists have 
at their command various instruments, based upon stereo- 
scopic principles, to develop vision in this class of cases, 
which are often of great service, in conjunction with the 
correction of the refraction errors, in reestablishing 
parallelism of the visual axes. 

While in far-sightedness there is an associated excess 
of convergence, in near-sightedness there is a deficiency, the 
near-sighted eye, in consequence of its adaption for the 
perception of near objects, being enabled to regard these 
without the accommodative effort necessary to a normal 
eye. Too slight associated impulses, therefore, are sent to 
the converging centres, and near-sighted eyes show a 
strong predilection to deviate outwards, to become what is 
popularly known as " wall-eyed." Fortunately, in diver- 
gent squint, there is not the same tendency to suppression of 
the visual image as has been noted in the convergent variety, 
for the eyes, though failing to* converge in harmony, main- 
tain their vision independent of one another. The early 
prescribing of the proper concave spherical lenses is indi- 
cated in this class of cases, conjoined with the building up 
of the adducting strength of the weakened muscles by 
proper exercises with prisms, etc. 

Congenital Squint. — Not all cases of squint are de- 
pendent upon errors of refraction, for in many instances 
the strabismus is present at birth. In this type of strabis- 



STRABISMUS, CROSS-EYE OR SQUINT 57 

mus, the muscles themselves are usually at fault, being 
faultily inserted into the globe, or, as sometimes happens, 
absent altogether. The degree of squint may vary in such 
cases from a slight deviation which is only manifest in cer- 
tain excursions of the eyes, to an extreme deformity. As 
in divergent squint, vision may not be compromised, as 
both eyes frequently participate in binocular vision in some 
parts of the field of fixation. The need of early correction 
is not so pressing, therefore, as in convergent squint. 
Xevertheless, prompt detection of this variety of squint is 
of great importance, in order that proper measures may be 
instituted to insure parallelism of the visual axes as soon as 
possible. 

Slight deviations, as in other varieties of insufficiencies 
of the muscles, may be corrected by means of prisms. 

To gain parallelism of the visual axes, however, and to 
insure the participation of both eyes in all their excursions, 
some form of operative treatment is usually necessary. As 
in the treatment of the other varieties of squint, the oper- 
ator has the choice of either weakening the muscles that are 
too strong by tenotomy, an operation which consists in par- 
tially or wholly loosening the tendinous attachment of the 
muscle into the globe, or of strengthening the weak muscles 
by a shortening process. These latter procedures are desig- 
nated as advancements, and consist either in shortening the 
muscle by a process of " tucking " or of dividing the muscle 
from its old attachment and sewing it forward into a new 
position on the globe. Tenotomy is a simple procedure, 
advancement an operation of some magnitude. Both re- 
quire experience and skill for their successful accomplish- 
ment. Tenotomies may be safely performed at an earlier 



58 HYGIENE OF THE EYE 

age ; generally, however, it is safer to wait until the ninth 
or tenth year of age before attempting advancements. 

As a rule, blind eyes tend to diverge, and it is generally 
useless to attempt to obtain parallelism in such cases by 
any form of operative procedure, for without the stimulus 
of vision to hold the eyes in fixation, such operations are 
usually futile, the deviations recurring after the primary 
effect of the readjustment of the muscles has passed. 



CHAPTER V 

THE INFLUENCE OF OPTICAL DEFECTS 
UPON THE GENERAL SYSTEM 

It may readily be gathered from the perusal of the 
previous two chapters that any decided derangement in 
the build of the eyes or in the proper balance of the ocular 
muscles may, under certain conditions, exert a profound 
influence upon the general system, and the daily experience 
of all specialists in eye diseases supports this supposition. 

Such phenomena are usually of reflex origin, and have 
their manifestation in organs which have some association 
with the eyes, by virtue of connections both near and 
remote, through the central nervous system. It is rare that 
these reflex symptoms arise in others than eye workers, 
who employ many hours daily in the close use of the eyes. 
At times, however, they are encountered in individuals who 
lead for the most part an outdoor life, with a minimum 
amount of eye-strain. 

When it is remembered that the eye may be regarded 
as an end organ of the brain and that of the 12 pairs of 
cranial nerves 6 have some connection with the eye, and 
that several of these have relationship with nerves supply- 
ing other important organs of the body, it is not surprising 
that ocular anomalies entail more or less derangement 
in the functions of these organs. The degree of impres- 
sionability of the nervous system in each individual has 
much to do with the appearance of such reflexes, and errors 
of refraction which would occasion no reflexes whatever in 
unresponsive individuals will, in a person of nervous dis- 

59 



60 HYGIENE OF THE EYE 

position, originate disturbances in the functions of the 
body of considerable moment. An examination of the eyes 
of such cases usually reveals an error of some magnitude. 
Probably the most common symptom caused by eye 
strain is headache. Indeed, it has been estimated that 71.3 
per cent, of cases who consult oculists suffer from some 
form of head pain. The pain from eye-strain may occur 
in any part of and all through the head, so that from its 
location alone it is impossible to differentiate headache 
from eye-strain from that due to other causes. Usually, 
however, pain over both or one eye is significant, but dull 
pain in the back of the head is scarcely less so, and pain in 
the temples and top of the head is frequently originated by 
eye-strain. The time of the occurrence of the head pain 
may, however, often establish a causal connection between 
it and eye-strain. Thus, it will be ascertained that a morn- 
ing headache was induced by the prolonged use of the eyes 
the night previous. In another patient, headache will ap- 
pear in the late afternoon, after an all day's labor at the 
desk, whereas on Sundays or holidays there is perfect free- 
dom from all such symptoms. It must be noted, though, 
in this connection, that headache may be just as likely in- 
duced by the strain of regarding distant as well as near 
objects. In fact, in many defects of the ocular muscles, 
distant fixation is more apt to give rise to distress than 
prolonged application at close range. In this class of in- 
dividuals, headache will appear in the morning after a 
night spent at the theatre or at a lecture, or will be occa- 
sioned by watching moving objects, as in crowds, or pass- 
ing objects when seated in a trolley or railroad car. If 
the patient be catechised sufficiently, a connection between 
some unusual near or distant use of the eyes may generally 



INFLUENCE OF OPTICAL DEFECTS ON SYSTEM 61 

be ascertained, and the clew given which will lead to the 
recognition of the cause of the trouble. 

A large proportion of the sub j ects who suffer from eye- 
strain present no associated ocular symptoms whatsoever. 
Indeed, it may be put down as a rule that eyes with red 
lids and other signs of congestion do not, as a rule, cause 
headache or other reflexes. The strain seems to be relieved 
by the local turgescence, and head symptoms are absent. 
Although the eyes themselves present nothing abnormal 
to the casual observer, it is often possible to elicit data 
which are at least suggestive that they are at fault. Thus, 
many subjects will complain of the print blurring after 
prolonged reading, of restricted distant vision, of occa- 
sional double vision, in fine of those symptoms usually de- 
scribed under the term of astlienopia. 

In many instances, however, there is nothing which 
serves to attract the attention of the sufferer to any ocular 
deficiency whatsoever, and the headaches are variously as- 
cribed by him to biliousness, hunger,. brain fag, and a variety 
of other causes. Others count themselves victims of an in- 
herited trait and resign themselves to a life of suffering. 
Despite the claims of some that migraine or sick headache, 
that distressing form of recurring head pain, with asso- 
ciated sick stomach and vomiting, and often accompanied 
by various forms of visual phenomena, i.e., the perception 
of flashes of lights, motes, etc. {vide p. 189) is invariably 
caused by eye-strain, experience teaches that while it is 
true that such attacks may sometimes be cured, they are 
more often only controlled, and oftener still entirely unin- 
fluenced by ophthalmic treatment. While migraine may in 
many instances be viewed as but a peculiar variety of 
headache and having but little relationship with the gen- 



62 HYGIENE OF THE EYE 

eral health, it may be symptomatic of serious disease within 
the brain, and its occurrence should always lead to a care- 
ful medical examination, with a view to determining its 
true nature. 

Not only may headache be induced by eye-strain, but 
other reflexes may also be occasioned by it, which mani- 
fest themselves in digestive disturbances. These may vary 
from flatulency, faulty digestion and its product constipa- 
tion, to nausea and actual vomiting. The accompanying 
schematic anatomical explanation (Fig. 25) demonstrates 
the connection of the nerves of the eye with those of the 
stomach and illustrates how such symptoms may arise. In 
consequence of ocular anomalies and the resultant strain, 
nerve energy that should have been expended elsewhere is 
diverted to the eyes, and the functions of the organs robbed 
of their proper stimulus suffer. The history of such cases 
is as follows : A patient who is accustomed to use his eyes 
much at short range suffers from indigestion almost con- 
stantly as long as he carries on his work. He interrupts 
his labors for a short holiday in the open air, away from 
his books, and his digestive symptoms vanish. He eats 
everything without difficulty. He returns to his desk and 
in a few days distress reappears. The ocular cause of his 
symptoms being unsuspected, his diet is looked into and 
certain articles of food denied him. He is enjoined to 
spend more time in the open air, and riding or golf is pre- 
scribed. By dint of this, of daily exercise and great cau- 
tion with his diet, his work is continued with more or less 
discomfort and restriction. Finally some one calls his 
attention to his eyes and he is properly glassed, and very 
shortly, to his amazement and gratification, he finds that 
his liver no longer gets out of order and that he can take 



INFLUENCE OF OPTICAL DEFECTS ON SYSTEM 63 



Ophthalmic ganglion 
Carotid plexus 
Infraorbital 



Second division 
fifth nerve 



First division fifth nerve 

, First division third nerre 
First division fifth nerve 

Nucleus third nerve 

Nucleus fifth nerve 



Meckel's ganglion 



Superior cervical 
ganglion 



Ganglion of the 

root 
Medulla of pneumogaa- 

trie nerve 
First cervical nerve 
Second cervical nerve 



Middle cervical ganglion 



Inferior cervical ganglion 



Pneumogastric nerve 




Stomach 



-7. / 

th'p Pvrr;^,w?^"l^*'^ diagram of the cerebrospinal and sympathetic nerve connections between 
ine eye and the stomach. fHnnsplI Pn^^^r «r,ri Kr.;ii„^ ">ri,„ ir.,^ „^^ *i,„ m^_„^.,„ <,.„* -m 



stomach. (Hansell, Posey and Spiller, "The Eye and the Nervous .Syste 



m.") 



64 HYGIENE OF THE EYE 

decided liberties with his diet without fear of evil con- 
sequences. 

The reader must not deduce from this that ocular dis- 
orders are responsible for all forms of faulty digestion; 
that ocular imbalance does, however, play an important 
contributing factor in many such cases is attested by the 
experience of many clinicians and ophthalmologists. 

Vertigo. — Vertigo, head swimming, or dizziness, may 
be due to a variety of causes. Heart disease is perhaps 
chiefly responsible for the majority of the cases, but any 
other condition of the system which temporarily or per- 
manently affects the equilibrium may operate as a causal 
factor. Ocular vertigo may be occasioned by errors of 
refraction or faulty action of the ocular muscles, and is 
usually excited by the use of the eyes at near work. Where, 
however, it is dependent upon some gross anomaly in the 
functioning of the muscles, it may be present constantly, 
and only relieved by closing the eyes. Under such cir- 
cumstances, vertigo is usually associated with double vision 
and the diagnosis of the ocular source of the dizziness 
patent. 

In other instances, however, cases in which the ocular 
error is but slight, the most searching test is often neces- 
sary to determine the seat of the trouble. The author has 
in mind a man of massive build and robust health, an im- 
portant personage in civic life, who was about to resign his 
position of responsibility on account of a troublesome 
vertigo which had been unrelieved by medical treatment, 
and who was entirely cured of the dizziness by the super- 
position of a weak vertical prism into his glasses. Ordi- 
narily vertigo, when dependent upon minor ocular defects, 
occurs in those who are run down, or whose eyes are weak- 



INFLUENCE OF OPTICAL DEFECTS ON SYSTEM 65 

ened from excessive near use. Nausea and vomiting may 
be attendant phenomena. The treatment of ocular vertigo 
may usually be accomplished by the adjustment of proper 
glasses, or by operation upon the eye muscles, and the cure 
which is usually effected earns the lasting gratitude of the 
patient. 

Car sickness is often dependent upon the same causes 
as ocular vertigo and may be entirely relieved in many in- 
stances by ocular treatment. 

Chorea or St. Vitus" Dance. — The frequently re- 
peated blinking of the lids, associated at times with twitch- 
ing in the muscles of the face, is often dependent upon 
eye-strain, and, as in the other affections just described as 
of reflex ocular origin, may be seen in association with ap- 
parently insignificant ocular errors, the intensity of the 
reflex phenomena excited by the eye-strain being less de- 
pendent upon the degree of the anomaly present than upon 
the impressionability of the nervous system of the indi- 
vidual afl*ected. 

The chorea of eye-strain must, however, be differen- 
tiated from true chorea, which is probably infectious in 
nature, with superadded psychical phenomena. Ocular 
or habit chorea usually occurs in children whose eyes are 
not alone at fault but whose nervous system is not equal to 
the strain of school life. A cessation of school work, tonics, 
and the like, are of service, but study cannot be resumed 
without a return of the grimaces, unless the correction of 
the ocular defect has been made. 

By removing the strain upon the nerve centres and 
thereby lessening their sensibility to peripheral impulses, it 
has been found in many instances that a painstaking cor- 
rection of any ocular error will often lessen, if not cure, 



6Q HYGIENE OF THE EYE 

the habit of wetting the bed, common with some children 
long past infancy. 

Faulty Position and Spasmodic Movements or the 
Head Due to Eye-strain. — In order that the body may 
properly perform its functions and all the organs act in 
harmony, a certain reciprocity must be maintained between 
the different parts. Nowhere is this reciprocity, this asso- 
ciation of action, better observed than in the movements of 
the head and eyes. On account of the protected position 
of the eyes and the direction of the plane of the orbit in the 
human skull, the field of sight is restricted much more in 
man than in some of the lower animals whose eyes are much 
more mobile, and were it not for the increase in the range 
of the field of sight which the rotation of the head affords, 
man would be unable to perceive many side objects without 
change of position of the entire body. Not only does the 
head, however, by its movements augment the range of the 
field of vision, but it also supplements the action of the 
extra-ocular muscles in the delicate task of maintaining 
proper visual axes. To properly perform this two-fold 
task, the head is provided with numerous and intricately 
acting muscles, and it is only when one remembers that there 
is scarcely a position assumed by either the eyes or head in 
which the action of both parts do not enter, that we realize 
how intimate the relationship between the muscles of the 
eye and those of the neck is ; indeed, it might be added the 
musculature of the entire body as well, for it is usual for the 
muscles of the trunk to be implicated in a greater or less 
degree in all vicarious positions of the head. 

The accompanying illustrations (Fig. 26) depict faulty 
positions of the head assumed by individuals with paralysis 
of eye muscles, in consequence of a compensatory effort to 



INFLUENCE OF OPTICAL DEFECTS ON SYSTEM 67 




HYGIENE OF THE EYE 



avoid the double vision and ocular vertigo occasioned by the 
palsy, the head being turned in the direction of the affected 
muscle, thereby supplementing its action, so that for every 





Fig. 27. — A, depicts the expression sometimes indicative of an overaction of the muscles 
puUinfe- the eyes in. B, weakness in the same group of muscles (Stevens, "Motor Apparatus 
of Eye." Courtesy, F. A. Davis Co.) 




Fig. 28. — Shows the compressed brow on one side and the elevated one on the other, 
sometimes observable when the eyes are not on the same horizontal plane, i.e., one eye looks 
higher than the other. (Stevens. Courtesy, F. A. Davis Co.) 



INFLUENCE OF OPTICAL DEFECTS ON SYSTEM 69 

variety of palsy there is a characteristic pose of the head. 
Similar deviations, though to a less extent, are observed in 
cases of latent trouble in the ocular muscles, and often are 
the means of calling the attention of the oculist to the faulty 
muscles. 

Associated with the tilting of the head, and in minor 
degrees of anomalies of the ocular muscles, occurring 
without any change in the position of the head, various 




Fig. 29.— Showing torticollis from vertical deviation of one eye. 

contractions occur in the muscles of the face, which find 
expression in the appearance of grooves and wrinkles, which 
at times entirely change the expression. The illustrations 
adjoining (Figs. 27 and 28) express the views of a well- 
known American oculist, who asserts that it is possible by a 
study of such changes in the lineaments to determine the 
particular muscles which occasion theme 

A condition of wry-neck which occurred in the prac- 



70 HYGIENE OF THE EYE 

tice of the author is illustrated by Fig. 29, the spasm in 
one of the principal muscles of the neck having been occa- 
sioned in consequence of an extreme tilting of the head, 
by the patient's effort to overcome the disturbance in vision 
following a paralysis of one of the muscles which elevates 
the eye. 

Another type of cases in this group is the occurrence of 
head jerking in association with oscillations of the eyeballs 
in you7ig children. In this disease the child moves its head 
rapidly, either from side to side or up and down, or at 
times with associated horizontal and vertical movements, 
while the eyes make rapid to and fro movements. This 
condition usually arises in children with rickets and other 
nutritional disturbances, in consequence of which the 
centres in the brain controlling the movements of head and 
eyes become impoverished at the time the child is learning to 
coordinate the movements of the eyes with those of the 
head; an initial eye lesion occurring, compensatory head 
movements appear. 

Oscillations of the eyeball {nystagmus) , either to and 
fro, rotary, or up and down, or combinations of one or all 
such movements, are sometimes observed. They occur for 
the most part in individuals with poor vision, are usually 
involuntary, and generally provoked by efforts to see ob- 
jects clearly. Heredity is a factor in some cases, the 
anomalous movements in the eyeballs being transmitted 
from generation to generation. 

Oscillations of the eyeballs may also arise in individuals 
whose work demands the direction of the eyes in abnormal 
and strained attitudes. Probably from an effort to steady 
the movements of the eyes and to transfer the strain from 
the most affected group of eye muscles, the head is often 



INFLUENCE OF OPTICAL DEFECTS ON SYSTEM 71 

held in peculiar positions and at times develops a slight 
tremor. The most striking instance of this acquired form 
of eye movements is that observed in miners — ^the so-called 
miner s nystagmus, the faulty movements of the eyes origi- 
nating in consequence of the unnatural position assumed by 
the miners in the shafts as they strike with their picks at 
the coal in the vein above their head. The insufficient illu- 
mination under which the work is carried on is also a con- 
tributing factor, nystagmus arising much less often in well- 
lighted mines. An entire cure is effected by the abandon- 
ment of mining, by prolonged rest to the eyes, and by the 
correction of any ocular deficiencies. 

Epilepsy. — This serious disease of the nervous system, 
with its associated attacks or convulsions and interference 
with the health of the brain, has important ocular symp- 
toms. The warnings, or " aurse," so called, which fre- 
quently make the subject of this disease aware of an 
approaching attack, are not infrequently connected with 
the eyes, and the patient's attention excited either by a 
sensation of muscle strain or double vision or by the appear- 
ance of some variety of visual perception {vide page 183) . 

By reason of the association of these eye symptoms with 
epilepsy, some have gone so far as to claim that eye-strain 
may actually originate the disorder, and that it needs but 
the careful correction of the eyes with proper lenses to ef- 
fect a cure. From the author's experience in the treatment 
of a considerable number of such cases, in the State Hos- 
pital for the Insane at Xorristown, and in the Pennsyl- 
vania Hospital for Epileptics, it would appear, however, 
that while the ophthalmologist can relieve and diminish 
the number of seizures in certain cases in which the dis- 
ease has been of not too long standing, and who present 



72 HYGIENE OF THE EYE 

some form of visual aura or subjective sign of eye-strain, 
he cannot cure epilepsy. It would seem proper, therefore, 
in view of the facts just cited, that every case of epilepsy 
which has not progressed into the last stages should have 
the benefit of a searching ophthalmological examination 
and a careful correction of the eyes with glasses or by 
operation upon the eye muscles where such is indicated. 
The cure of most forms of epilepsy has not yet been dis- 
covered, but our knowledge of this complex disease con- 
vinces that the ocular phenomena observed in connection 
with it are merely symptomatic and associated, and by no 
means essentially causal. 



CHAPTER VI 

SCHOOL LIFE; ALSO SOME HINTS REGARDING 
THE CARE OF EYES IN GENERAL 

Undee this caption may be considered the various 
phases of the answer to the question, " How shall I best 
care for my eyes, that I may conserve vision and keep my 
eyes in a healthy and useful state as long as I live? " It 
will be shown in later chapters that the eyes are healthy 
only so long as the body is healthy, and that ill-health is 
always deleterious to the organs of sight. It may be well, 
however, in this connection to emphasize the particular 
evil of bad health in childhood upon the eyes and to warn 
against their overuse in early life during illnesses or con- 
valescence from them. Attacks of measles and other fevers 
should be followed by long periods during which the eyes 
are used but little at close work, for if this precaution is 
not followed, near-sightedness and astigmatism will likely 
develop in consequence of the softening and congestion 
of the ocular tissues which so often accompany these 
conditions. 

Many hours daily shovild be spent in the open air to 
tone up the bodily vigor and to rest the eyes in the parallel- 
ism of the visual axes associated with regarding distant 
objects. 

From early childhood the eyes should be carefully 
cleansed of mucus and the lashes freed from all tenacious 
particles of conjunctival secretion by morning and even- 
ing bathing with a warmed saturated solution of boracic 

73 



74 HYGIENE OF THE EYE 

acid. Reading or studying in the morning before break- 
fast, or at least before nourishment of some kind, should 
be discouraged. 

The books and magazines read earliest should have 
large lettering and striking pictures and all puzzles and 
games should be prohibited which have small figures or 
dazzling combinations of form or color. Many devices 
in common use in kindergarten instruction are harmful, 
owing to the concentration of vision which they necessitate, 
and teachers and parents would do well to choose only those 
which are free from these objections. While modern archi- 
tecture and the movement to insure proper housing have 
done much, by proper window-spacing, to insure sufficient 
daylight in dwellings, many houses, especially in city 
streets, receive insufficient light from the sun. Under such 
conditions, desks and playthings must be brought nearer 
the windows, and the children routed out of dark corners. 
Children should be taught from the earliest age never to 
gaze long upon any near objects brightly illmninated 
by the direct rays of the sun. Exception must be taken 
also to the harmful practice of riding babies in coaches 
while they are lying flat on their backs with the full glare 
of the sun falling upon their faces. All such coaches 
should be provided with tops and lined with some green 
material. 

As insisted upon in another chapter, children should 
be protected from all toys and articles with sharp edges or 
points which can possibly injure the eyes. 

In the chapter dealing with proper artificial lighting, 
valuable information is given regarding this essential to the 
conservation of good eyesight, but it may be emphasized in 
this connection that what is necessary for the eyes of adults 



SCHOOL LIFE AND CARE OF EYES 75 

is doubly so for the eyes of children, and that under no cir- 
cumstances should children be permitted to use their eyes 
except under the best lighting conditions possible. When 
twilight supervenes, artificial lights should go on, unless 
the wise parent utilizes this witching hour to rest the eyes 
of the young by such tales and anecdotes as will serve t:) 
amuse and instruct. Xo reading should be permitted by 
the flickering light of the open fire. 

School Life. — Unless under exceptional circum- 
stance of domestic utility or necessity, children should 
rarely be permitted to start school life until they have 
passed their sixth birthday. Few are sufficiently devel- 
oped or sturdy enough to properly endure either mentally 
or physically the discipline and exactions of application 
and study before that age. A^Hien there can be no home 
training, kindergartens are useful, but usually some sup- 
plementary form of home instruction may be instituted 
in earlier years, which will serve to prepare the child for 
understanding and appreciation of the first year of real 
school life. 

Examination of Eyes. — Before entering upon the 
duties of school life, it is essential that parents and edu- 
cators should have a definite knowledge of the visual con- 
dition of each child, and no child should be permitted to 
commence his studies until he has been subjected to a 
careful ocular examination. When possible, this should be 
made by a trained oculist and all disqualifying defects cor- 
rected by proper glasses. In the examination of the very 
large number of children in the public schools of the large 
cities, however, such expert supervision is not always feasi- 
ble, and the visual tests are often necessarily performed 
by teachers or general medical practitioners, reference 



76 HYGIENE OF THE EYE 

being made to the trained specialist of such cases which 
manifest some considerable defect. 

Such tests are of paramount importance not only for 
the parent, who becomes acquainted for the first time with 
the existence of defects which may cause a relinquishing 
of plans for the future career of his child, but also for the 
child, as the correction of detected errors of refraction en- 
ables him to enter upon school life upon equal terms with 
his fellows with normal eyes, which would not have been 
the case had his visual deficiency not been recognized. In 
years past, too many scholars have suffered from head- 
aches or have been adjudged stupid and backward and 
punished accordingly, by reason of defective vision alone. 
As will appear presently, special classes and individual 
forms of instruction have been devised for those with very 
poor vision, so that a thorough comprehension of the visual 
status has become of prime importance to all concerned in 
education. 

School life begun, the educators in charge should see 
that the periods of instruction are not too prolonged (for 
beginners half -hour lessons are amply long) , and that each 
period be followed by a short recess, which should never be 
forfeited as a punishment for bad behavior. These periods 
of relaxation will give the eyes opportunity to glance at 
objects at long range, and will permit of a change of air 
and scene. In the higher classes, the best authorities agree 
that lessons should not last more than 45 minutes, and 
that each should be followed by a recess of at least 15 
minutes. In arranging the order of subjects for study 
care should be given that two periods in which the 
pupils use their eyes at near range should not follow 
each other. 



SCHOOL LIFE AND CARE OF EYES 



77 



The three great requisites necessary in all school rooms 
are the following: adequate lighting, proper seating facili- 
ties, and suitable books. 




Fig. 30. — MoQlthrop movable and adjustable school chair, Model B, manufactured by 
Lanffslow, Fowler Co. 

The first of these has received full consideration in a 
special chapter. Regarding the second, the general rule 
should ohtain that in reading, the distance of the eves from 



78 HYGIENE OF THE EYE 

the book should be as great as the height of the child per- 
mits. Children have a tendency to lessen the distance, both 
from the unconscious desire to obtain the larger image of 
the object which is thrown upon the retina when viewed at 
close range, as well as from the increased muscular fatigue 




Fig. 31. — The " Princeton " adjustable desk and chair, manufactured by the New Jersey 

School Furniture Co. 

consequent upon maintaining an upright posture, but this 
practice should be combated, as it increases eye-strain and 
favors the development of spinal curvature. 

To secure proper postural conditions, all desks should 
be made of adjustable parts, so that they may be fitted to 
the varied heights of the pupils. The tops of desks should 
be slanted, so that they make an angle of approximately 



SCHOOL LIFE AND CAEE OF EYES 79 

45° with the floor line. A distance of from 14" to 16" 
should be maintained at all times between the eyes of the 
pupil and the book under examination on the desk. A 
popular model and one which has been endorsed by 
Madame Montessori is shown in Fig. 30. 




Fig. 32. — Adjustable desk and chair, manufactured by the American Seating Co. 

The desk is provided with a sliding desk top, which 
can be pushed aside at will, to permit of the pupil's readily 
rising and maintaining an upright posture, a restful change 
after a long period of sitting. Other admirable desks are 
shown in Figs. 31, 32, 33, and 34. 

Burgenstein, in his excellent book on " School Hy- 



80 



HYGIENE OF THE EYE 



giene," recommends half -yearly measuring of the school 
population and allotment of seats according to the results 
found. He has devised a measuring rod useful for this 
purpose with devices marked upon it corresponding to the 
various sizes of desk. Faulty postures assumed at im- 
properly adjusted desks are responsible for much evil, for 



Fia. 33. 



Fig. 34. 




Figs. 33 and 34. — Adjustable racks designed by the Paatural League Society. 

not only may visual disorders arise in consequence of too 
httle distance between the eyes and the desk, but various 
spmal curvatures may be induced which may seriously im- 
pair health throughout life. The accompanying illustra- 
tion (Fig. 35) gives a graphic demonstration of one of 
these conditions. 

To relieve the eyes of the very young from the strain of 



SCHOOL LITE AND CARE OF EYES 



81 



close work, it has been suggested that in the first two years 
of school life all writing should be upon the blackboard in- 
stead of upon paper. As the slate and paper blackboards 
which are commonly in use after a time become gray from 
chalk dust, so that figures and letters done in white chalk 
are not always legible, it has been proposed to substitute 




Fio. 35. — Distortion of the trunk while working at a too high desk. 



mural tablets of black glass, which have the advantage of 
being exceedingly durable, of preserving a perfect writing 
surface, and of being readily cleaned by an ordinary damp- 
ened sponge or rubber. Instead of black glass boards, 
upon which white chalk is used, dark green boards 
have been introduced into a number of schools and yel- 
low crayons used for contrast. With this exception, it 
is generally accepted that colored crayons should be 



82 HYGIENE OF THE EYE 

used only in artistic instruction, or for such purposes as 
map drawing. 

All blackboard work should be in large writing and the 
boards so placed that they receive sufficient illumination. 
They should never be so highly polished that reflected light 
from them dazzles. Large shiny blackboards on the wall 
opposite a window have been proven to take away much 
reflected light, and those with dull surfaces are always to 
be preferred. 

When unilateral lighting is used, blackboards may 
safely be placed on three sides of the room. They should 
never be put between windows, to avoid the possibility of 
the direct light from the window entering the eye. When 
the boards are placed opposite the windows, the eyes are 
adjusted only to the light reflected from the board, and, if 
the illumination is sufficient, vision is easy and restful. The 
wall space opposite windows ought to be saved as much as 
possible for this purpose. 

In well-lighted rooms, the danger from the absorption 
of light by blackboards is negligible. On dark days and in 
rooms with insufficient illumination, some relief may be 
obtained by drawing light colored window- shades over the 
blackboards. These may be fastened just above the board 
and pulled down when more light is needed and when the 
board is not in actual use. 

The style of writing is of importance, vertical writing 
being conducive to a better position of body and conse- 
quent proper separation of eyes from objects regarded 
than the slanting variety. 

Composition of Books. — Of paramount importance is 
the composition of the books which the child will study. 



SCHOOL LIFE AND CARE OF EYES 83 

In classes for the youngest children, i.e,, those under seven 
years of age, instruction is best given by means of black- 
boards, large printed diagrams, pictures, and other objects 
readily seen at a distance, and teaching by word of mouth. 
After that age, only such books should be chosen as con- 
form with recognized standards regarding paper, print, 
etc. Thus the paper should be without gloss, to avoid 
dazzling reflections. Pure white or paper slightly toned 
toward cream color afford the greatest contrast with the 
ink, which should be black. A hard pressed paper is to be 
preferred, as a soft paper is readily soiled, its surface easily 
rubbed off and the detritus injurious. The impressions of 
the type should never be permitted to show through from 
the other side, and care should be taken that there is ample 
time for drying the ink before the papers are bound 
together, to prevent blurring of the type impressions. 
All illustrations should be of good size and the printed 
text should not extend in narrow lines at the side. All 
explanatory legends of pictures and diagi^ams should 
be in type of a good size, which can be easily read. 
In preference to reproducing illustrations on highly 
glazed sheets, half-tone prints on matt paper should be 
employed. 

An average length of line is to be preferred. Lines 
which are too long make it difficult for the eyes to pass to 
the next; those which are too short necessitate too fre- 
quent a change in direction of the ocular movements. 
Double columns should not be employed. Good margins 
are restful to the eye. 

The size of the type-face is the most important factor 
in the influence of books on vision. The following speci- 



84 HYGIENE OF THE EYE 

mens of type have been reproduced from a report ^ of a 
committee appointed by the British Association for the 
Advancement of Science to study the influence of school 
books upon eyesight. They conform with the dimensional 
rules proposed by the committee and show the smallest 
sizes which the committee regards as permissible during 
the age periods cited ( Fig. 36 ) . 

Medical school inspection has done much to improve 
the condition of children during school life and the atten- 
tion to ocular conditions and the insistence upon the cor- 
rection of all existing errors of refraction has been of the 
greatest value. In the year 1895, before the institution of 
school medical inspection in Philadelphia, out of 33,000 
children entering the first grade, only 53 per cent, reached 
the fourth grade, and only 13 per cent, reached the eighth 
grade. In the year 1905, when school medical inspection 
started in this city, out of 34,000 children entering the 
first grade, 64 per cent, reached the fourth grade, and 22 
per cent, the eighth grade. '^ 

As Wessels has pointed out, " the correction of ocular 
insufficiencies not only increases the efficiency of the pupil, 
but has an important economic value as well, because if a 
child is backward and remains in the same class for two or 
three years, it is costing the State two or three times as 

■^ This report, obtainable at the offices of the Association, 
BurHngton House, W., London, is of exceeding' value and is recom- 
mended to all desirous of further information upon the printing 
of school books, etc. A paper by Black and Vaughn, of Milwaukee, 
entitled " Protection of the Eyes of School Children," is also of 
value. 

^ Lewis C. Wessels, M.D., Ophthalmologist, Bureau of Health, 
Philadelphia, Pa. 



SCHOOL LIFE AND CARE OF EYES 85 

Fig. 36. 

AGE SEVEN TO EIGHT 

This type may be used for books 
to be read by children from seven 
to eight years old. The letters are 
larger than the minimum given in 
the typographical table. 



AGE EIGHT TO NINE 

This type is suitable in size for books to be 
read by children from eight to nine years old. 
The size of the letters is slightly larger than the 
minimum given in the typographical table. 



AGE NINE TO TWELVE 

This type is the smallest suitable in size for books 
intended for readers over nine years old. The size 
of the letters is equal to the minimum given in the 
typographical table. 



OVER TWELVE 

This type is suitable in size for books intended for practised 
readers over twelve years old. The size of the letters is in 
conformity with the smallest dimensions given in the typo- 
graphical table. 



86 HYGIENE OF THE EYE 

much as it should to teach that child. In Philadelphia it 
costs about $35 per year to teach each pupil. A child is 
compelled to attend school between the ages of six and 
fourteen years inclusive, eight years in all. Under normal 
conditions a pupil 14 years old reaches the eighth grade 
at a cost to the State of $280; if on account of defective 
vision the child only reaches the fourth grade in that time, 
it has cost the State $280, but with only $140 worth of 
result — a loss to the State of $140. The loss to the child 
is considerably more, because at the age of fourteen he is 
likely to be put to work, poorly equipped for the struggle 
for existence, his earning power is curtailed for the want of 
an education, so he can contribute little toward his own 
support, that of his family, or of the State. So again the 
State loses, and all for the want of suitable glasses for 
the child." The City of Philadelphia furnishes glasses 
free to all those who are too poor to provide them. From 
1908 to 1913, 6310 pairs of spectacles were provided in 
this way. 

In recent years educators and ophthalmologists have 
realized the advantages which would be gained by pupils 
and teachers if scholars with poor vision received their in- 
struction in separate classes. There has accordingly, in 
several centres, been instituted special classes for (Children 
who are very highly myopic and for those who are par- 
tially sighted from other causes. The following is an out- 
line which has been adopted in London for the conduct of 
such classes ^ : 

^ " The Problems of the Education of the High Myopes and of 
the Partially Sighted," N. Bishop Harman, F.R.C.S. 



SCHOOL LIFE AND CARE OF EYES 87 

" 1. Elementary school for easy treatment as regards 
eye work. 

" 2. Elementary school for oral teaching only. 

" 3. Myope class. 

" 4. School for the blind and partially blind. 

" 5. Invalided temporarily or permanently." 

Harman says : " To make clear the nature of the defect 
of the eyes of these children and the limitation of the educa- 
tion they will receive, the matter is explained personally to 
the parent of the child, and an explanatory^ notice is issued. 
It is equally necessary that the teachers to whose care 
these children are comaiitted should be clear as to the neces- 
sity for closely watching and limiting their work, and to 
this end a circular letter is sent to the head teacher of the 
school to which any such child is admitted." 

In London, children with a myopia of from 5 to 15 D., 
and with a corrected vision varying from 6/18 to 6/24 
are admitted to the myopia classes. These classes are all 
connected with the ordinary schools as "(1) a better 
scheme of work can be provided by this association; and 
(2) to establish the class as a separate unit is to run the 
risk of the children leaving school with a special mark 
upon them." The scheme of work outlined for these classes 
is as follows : 

"(1) Oral teaching with the normal children for such 
subjects as can be taught orally. 

" (2 ) Literary work such as is necessary for the knowl- 
edge of the ordinary means of communication to be learned 
without books, pens, or paper, but by the use of black- 
boards and chalk, the writing to be done in free-arm 
fashion. 



88 HYGIENE OF THE EYE 

"(3) A full use of every sort of handicraft that will 
develop attention, method, and skill, with the minimum use 
of the eyes." 

In his valuable paper, Harman goes on to say : 

'' The Class-room. — ^The one necessity of a class-room 
for myopes is perfect natural illumination. Artificial 
lighting for these rooms is a negligible consideration. All 
work other than physical exercises, oral lessons, or games 
is suspended immediately artificial light is required. 

" The ordinary school desk is unsuitable and the spe- 
cial desks in use provide for each child a full-sized black- 
board suitably sloped and at a convenient height for sitting, 
and also a full- sized horizontal table for handiwork. It is 
convertible from one use to the other by merely lifting the 
board. Each room has fitted all around the walls a band of 
blackboard. The boards are fixed so that they are avail- 
able for both teachers and pupils without requiring any 
adjustment. 

" When one group of children is taking oral lessons 
with the normal sighted in the ordinary school, the teacher 
will be employed in giving lessons requiring writing, arith- 
metic, or manual work to another group. The number of 
children that any one teacher can deal with at the same 
time must of necessity be less than the same teacher could 
cope with in an ordinary school. Individual teaching is 
much more necessary. Further, the desk fitting — the com- 
bination blackboard and table — takes up the room of an 
ordinar}^ dual desk. Experience shows that the greatest 
number any teacher can deal with successfully in any class 
working at the same subject and at the same time is 
twenty. 



SCHOOL LIFE AND CARE OF EYES 89 

'' The Curriculum, — The oral teaching is taken with the 
normal children in the ordinary school with which the 
myope class is associated. By this means the myopic 
children are kept up to the standard of knowledge of 
their normal colleagues, and have the benefit of mixing 
with them in class under the oversight of the regular 
teachers. 

" The hterary work of the children is done in the myope 
class upon the blackboards provided for each child, and 
upon the wall-boards. Letters must be large, and the chalk 
lines broad and strong, and to secure this the chalk sup- 
plied should be square-edged and of double the measure of 
the stock size. The small desk blackboards are marked 
with white lines two inches apart and the wall-boards four 
inches apart. 

" In the higher standards the need of some permanent 
record of the work of the children is felt; and in the 
higher standards exercise-books are being tried of a novel 
pattern. They are made up of large black paper sheets, 
and the wi'iting is done with white crayon, which gives a 
record of fair durability, but it can be washed off if de- 
sired. The exercise-books are clipped on to the desk black- 
boards, and the wi'iting is done free-arm fashion as though 
on the blackboard, so that none of the dangers of ordi- 
nary writing, such as stooping over the work, are involved. 
The eldest of the pupils are allowed to make a permanent 
record of their work by printing. Two sets of printing 
types are provided for the use of each class. They are 
rubber faced black-letter types, one of one-inch height, the 
other of two-inch height. These letters are mounted on 
wooden blocks, and the blocks are fitted with lateral pegs 
and holes, so that they can be joined together to form 



90 HYGIENE OF THE EYE 

words. The words are set up and printed upon large 
sheets of white paper, the record is permanent, and goes 
to form a class library of scrolls which are useful for 
subsequent teaching. 

" Physical exercises enter largely into the time-table, 
and attempts are made to associate some of the games with 
the instructional work, e.g., large sheets of scenic canvas are 
now supplied to two schools that have sufficient floor space ; 
on these the teachers paint outline maps of difl'erent coun- 
tries, marking out the position of the principal cities, rivers, 
mountains, etc. ; the children walk about on the floor-maps, 
learning their geography by travelling it in miniature. 
With a teacher of resource such methods of instruction 
possess endless possibilities of interest. 

"The most difficult section of the work to arrange is 
the manual training. Whatever the work done, it must be 
such that the fixed attention of the eyes is not demanded. 
For that reason all sewing- work is prohibited ; it has been 
tried with a few of the elder girls but was quickly stopped. 
Knitting, on the other hand, fulfils the necessary condi- 
tions ; a child that has any aptitude for it soon learns to do 
it automatically and with little use of the eyes; such chil- 
dren are allowed to practise it. The junior children (both 
boys and girls) are taught paper folding, stick laying, 
felt weaving in colors, and knitting. The seniors and some 
juniors are taught modelling maps, rough woodwork 
where measuring can be done with rulers marked with 
quarter inch marks. Advanced basket work is taught ac- 
cording to the advanced scheme on workshop principles 
(but not including raffia work, which is too fine). Bent 
iron-work is quite satisfactory, particularly for boys; 
possibly also the netting of hammocks, tennis nets, etc., 



SCHOOL LIFE AND CARE OF EYES 91 

for the girls cookery and laundry of a simple kind, just 
sufficient to give an intelligent insight into the arts of 
housewifery. 

" These crafts are taught as a training in attention and 
care; it is not intended that any of the children should 
enter into competition with the blind in doing this work; 
for that reason any particular kind of this work is not 
continued to the point where rapidity and skill are reached. 
The scheme of education in view for the myopes is not 
merely technical but general. Many of these children are 
of high intelligence, and a good general training with 
special attention to the development of thought, initiative, 
a good bearing, and clear speech free from objectionable 
accent and idiom, will fit them for positions of usefulness 
and responsibility of the in- and out-door type, such as 
small traders, collectors, agents, visitors, etc. This kind 
of occupation presents no risk to the eyesight. 

" There is great need for the discovery of more varie- 
ties of suitable manual work, especially for the use of the 
older boys. What is wanted in particular is work that can 
be done in the standing position. Whoever has under 
consideration the suitability or otherwise of manual tasks 
for these children has need to consider it from a totally 
different point of view from that necessary with ordinary 
children. With the ordinaiy child there has only to be 
considered the educational and disciplinary value of the 
work, and possibly the ultimate direct utility to the child, 
although I maintain that this is of no consideration in 
comparison with the disciplinary value. But with the 
myopes there is another matter to be considered. We 
must ask — ^Can the child do this particular sort of work 
without undue or too prolonged stooping? Judged by 



92 HYGIENE OF THE EYE 

this test there is a great diiFerence between such tasks as 
carpentry and bent-iron work. In carpentry the head is 
almost always bent downwards towards the bench, it is 
quite useless to attempt to raise the bench to a near level 
of the eyes to prevent stooping, for then the muscles of 
the arms and shoulders lose all power over the tools, and 
the work is unduly fatiguing. Bent iron- work, on the 
other hand, can be done sitting or standing, the table may 
be at a comparatively high level, and best of all the work 
is done for the most part with the eye looking straight 
forward. I have now under consideration the possibility 
of teaching weaving on frames of mats, carpets, and tapes- 
try, work that could be done standing to frames hung on 
the walls. If such work as this should prove practical it 
will be a valuable addition to our list of suitable handi- 
crafts. 

" I should like once more to emphasize the idea that 
handiwork as taught in these classes for the myopes is in 
no sense a utilitarian affair, it is not done as an apprentice- 
ship to a life-long work, such as is the case with the blind. 
It is taught as Latin is taught by the public school-master. 
The Latin school^master has long since given up the plea 
of the ' utility ' of Latin as a ' leading to vistas of classi- 
cal literature,' for the logic of circumstances has driven 
him to admit, albeit with becoming reluctance, that his 
pupils never gain more than a nodding acquaintance with 
the language, but he is strongly entrenched behind the 
statement that the learning of Latin is the best of all 
mental disciplines. Handiwork is to the myope school 
what Latin is to the public school, it is the one great train- 
ing in care, precision, and control. 

" There is no intention of teachinor a form of liveli- 



SCHOOL LIFE AND CARE OF EYES 93 

hood, but of training in methods that will subsequently be 
valuable in some suitable form of livelihood. This will 
be made plain when the various forms of work for which 
myopes are suitable are considered. After examining 
a long list of the available occupations for London boys 
and girls, I have drawn up the following as those for 
which the myopes are fit. There are two grades of 
work ; those most suitable for them, and those of secondary 
suitability. 

Boys 

First selection: 

Nursery gardening. 

Poultry farming. 

Messengers. 

Assurance agents. 

Travellers and canvassers. 

Rent collectors. 

Hawkers and street traders. 

Shopwork under good conditions. 

Piano-tuning. 

Second selection: 

Stick and pipe mounting. 

Basket-making. 

Some branches of brush-making. 

Girls 

First selection: 

Florists' work. 

Waitresses in tea shops. 

Dairy shops. 

Under nursemaids (no sewing). 

Creche attendants. 

Helpers at mothers' schools. 

Helpers at special schools and dining centres. 



94 HYGIENE OF THE EYE 

Showroom work. 

Light warehouse work (packing). 

Second selection: 
Box-making. 
Cork-sorting. 

Envelope folding, cementing, and black-bordering. 
Show-card mounting. 
Some branches of brush making. 
Stockroom work. 

" These lists show at a glance that the kinds of work 
placed in the first and most suitable selection are of the 
outdoor type, or those that enable the worker to be out and 
about, standing and moving, and with a minimum of close 
eye work. These kinds of work are doubly suitable, for the 
general health is likely to be the better for the freedom of 
movement enjoyed, and with the improvement in the gen- 
eral health the state of the eyes is likely to be benefited. 
Next after these comes the second selections, all these are 
of light tasks, that do not unduly involve the use of the 
eyes ; but they involve sitting and stooping throughout the 
whole period of work, conditions that are neither good for 
the body nor for the eyes. When, therefore, we look at 
the teaching and practice of manual work in the myope 
class in the light of the possible future of the children, it is 
evident that we want no more of it than is necessary to 
teach them methods and habits of precision. And just so 
much as will engage their minds with the possibilities of 
creating things as will withdraw them from the fatal 
snare of living in a world of reading and book-thinking. 
The manual work serves as both a discipline and a 
distraction." 

The Partially Sighted and the Partially Blind. 



SCHOOL LIFE AND CARE OF EYES 95 

— Under this class is grouped border-like cases which 
differ only from the blind in the degree to which vision 
has been reduced by the various diseases which have low- 
ered visual acuity. 

The conditions which are responsible for blindness in 
children have been classed by Harman under the following 
heads : 

1. Blindness due to causes which are in their nature 
accidental. 

2. Blindness due to general disease in which the child 
is born and shapen. 

3. Blindness due to congenital deformities. 

The children in the first group are normal save for 
lowered vision. Those in the second, however, according 
to Harman, which comprises 30 per cent, of the total child 
blind, bear the evidence of disease elsewhere, and are 
often mentally inferior. The third group comprises about 
20 per cent, of the partially blind and is often associated 
with defects in other organs. In dealing with scholars in 
these groups Harman states: " The state of their vision 
cannot be the sole determining factors of their places of 
education; the likelihood of their educability in view of 
the nature of the disease that made their eyes defective 
must be considered, and also the possibility of this same 
disease reasserting its maleficent influence and destroying 
still further both sight and wits. The case of a child with 
damaged eyes the result of ophthalmia neonatorum is 
simple of determination, if it sees 6/18 it is a fit subject 
for a myope class, its wits are as likely to be good as any 
ordinary child, and there is no likelihood of the recurrence 
of the inflammation of the eyes that damaged the sight in 
the beginning. It is otherwise with the child whose eyes 



96 HYGIENE OF THE EYE 

have been damaged by some inflammation springing from 
a syphilitic inheritance. That disease affects the whole 
body, and there is too often a recurrence of the disease that 
will still further reduce sight or even destroy the remnant, 
and at the same time so benumb the mental faculties as to 
lay waste all past educational gain, and efl*ectually pre- 
vent any future effort. With such a child the admission 
to a myope class, even though justified by the character 
of the vision existing at the time of examination, must be 
the subject of special note, that the child be not pressed 
or allowed to enter into competition with its short-sighted 
and smart-witted colleagues, lest the strain of the work 
reduce its bodily resistance and induce a relapse of the 
disease that originally brought it there." 

Special classes for children with defective eyesight have 
been in operation in Boston and Cleveland for several 
years past and are about to be installed in several other 
American cities.^ 

Some Hints Regarding the Care of the Eyes 
IN General 

While the importance of properly caring for the eyes 
is not as great in adults as in children, the formative 
period of the growth of the eye having passed and with 
it the greatest danger to the development of ocular errors, 
nevertheless the eye remains a more or less sensitive organ 
until death, and the wise man will naturally conserve its 
strength as far as he is able. With the extraordinary de- 

* Those interested in the education of children with defective 
eyesight would do well to obtain " The Eighth Annual Report of 
the Massachusetts Commission for the Blind, 1914." 



SCHOOL LIFE AND CARE OF EYES 97 

mands placed upon the eyes by reason of the increased 
desire to read, through the multiphcity of magazines and 
books which are constantly published and the ease afforded 
their use by the excellence of present-day artificial light- 
ing, there is much danger of the abuse of these organs. 
Common-sense dictates, therefore, that short periods of 
rest should interrupt all kinds of close work, during which 
the eyes should be directed for a time out of the window or 
on distant objects. After a day of continuous application 
in office work, it is unwise to devote more than an hour or 
possibly two hours to reading in the evening. A word of 
caution may be addressed to those who make a practice of 
reading in a recumibent posture, for under such circum- 
stances it is difficult to regard the book at a favorable angle. 
If for any reason, such as illness or fatigue, reading 
must be pursued in this attitude, care should be given 
that the body is made as upright as possible, and that 
the object regarded is held well below the horizontal plane 
of the eyes. 

Reading or close work should never be persisted in 
when drowsy or physically tired. The ocular muscles are 
relaxed under such conditions and are only stimulated 
into action by a conscious effort of the will. 

Veils, though usually worn for other purposes, may be 
useful in protecting the eyes from glare and dust. Light 
chiffon veils are useful for this purpose, black, blue, and 
green being the preferable colors. Dotted and very thick 
veins should never be worn. 

Books printed in very small type or on poor paper 
should be discarded, and better editions obtained. On ac- 
count of the attendant vibrations, reading on trains and 
moving vehicles of all kinds is more or less injurious and 

7 



98 HYGIENE OF THE EYE 

should never be practised by a poor illumination. In- 
dividuals with weak eyes should reduce their newspaper 
reading to a minimum and this only in a good light, on 
account of the poor type and paper generally used in this 
popular form of literature. 

As the health of the eyes is dependent in large meas- 
ure upon the health of the body, it behooves the individual 
solicitous of his ocular strength to properly care for his 
physical condition. One or more hours should be spent 
daily in the open air and walking should be practised when 
the more active exercises cannot for any reason be indulged 
in. A plentiful supply of fresh air should enter the sleep- 
ing-room, which should be absolutely free from light of 
any kind. The bowels must be kept regulated and par- 
ticular care given the teeth and the nasal passages, as dis- 
orders of these neighboring structures frequently give rise 
to ocular symptoms. 

If the eyes feel hot and uncomfortable after exposure 
to irritants or undue strain, they may be washed with an 
eye bath containing a saturated solution of boracic acid. 
Bathing the closed lids with either very warm or cold water 
is refreshing and beneficial. The habit practised by some 
of partially immersing the head and opening and closing 
the eyes under water is not to be recommended. 

Certain amusements at present much in vogue are 
somewhat harmful to the eyes. Among these may be 
mentioned automobiling in open cars and the moving 
picture theatres. The former is tiring by reason of the 
rapidity with which the eyes must adapt themselves to 
passing objects and from the fixed gaze of the driver 
and his anxious passengers upon the road. Suitable 



SCHOOL LIFE AND CARE OF EYES 99 

goggles will relieve the irritation of the eyes from wind 
and dust. 

Moving Pictures. — ^\¥hile the great majority of those 
who suffer from eye-strain after watching moving pictures 
can usually obtain relief from properly fitted glasses, the 
character of the films is sometimes of such a nature that 
there is no escape from more or less ocular pain, even 
though they be regarded for a comparatively short time. 
Usually the promoters of moving picture theatres, alive 
to the demands of the public, furnish excellent films and 
do what they can to insure the comfort of their patrons. 
Motion pictures, however, have become such a universal 
source of instruction as well as amusement, that it seems 
wise to insist upon several essentials in regard to them. In 
the first place, glass screens should be preferred to all others, 
this type of screen producing an ideal reflecting surface 
and producing pictures without glare and with a minimum 
of distortion. Experts agree that the auditorium should 
be as light as possible without obscuring satisfactory de- 
tail in the picture. The indirect system of lighting is to be 
preferred for this purpose. 

When possible, a seat should be chosen near the centre 
of the house, and within natural limits, the farther one is 
seated from the screen the better. Films should be dis- 
carded after they become scratched and " rainy." Steadi- 
ness and the absence of flicker in the picture may be ob- 
tained by mounting the projecting machine on a solid 
foundation, by proper apparatus and skilful adjustment 
by a capable operator. Finally, a period of rest should 
be permitted between the reels to ofl*set the fatigue of 
concentration. 

AuTOMOBiiJNG. — In addition to irritation and strain 



100 HYGIENE OF THE EYE 

upon the eyes occasioned by automobiling already referred 
to, there is another ocular phase of this popular means of 
locomotion which demands consideration; namely, the 
necessity that the driver of the car possesses a requisite 
amount of sight. Many European cities assure this be- 
fore granting a chauffeur's license, and it would be well if 
this practice were generally adopted in our own country. 
Two good eyes are essential, for a restricted vision in one 
eye limits the field of vision below the safety point. Near- 
sighted drivers who depend upon lenses to give them ade- 
quate vision, should be rejected, as the exposure to rain 
and fog which is at times necessitated in bad weather, 
mists the glasses to such an extent that they become 
useless. 



CHAPTER YII 

ARTIFICIAL LIGHTING 

By Herbert E. I^t:s, Ph.D. 

FORMER YICE-PRESIDEXT OF THE ILLUMINATING EXGINEER- 

IXG SOCIETY^ CORRESPOXDIXG MEMBER OF THE ILLU- 

MIX-ATIXG EX^GIXEERIX^G SOCIETY OF GREAT 

BRITAIN 

INTRODUCTION— ABOUT KINDS OF LIGHTS 

Good artificial lighting is not a question of the kind of 
illuminant but of how the illuminant is used. Oil, gas, 
and electricity can each be used to produce satisfactory 
lighting, and each can be abused. The modern lighting 
specialist can so plan a scheme of illumination that any 
kind of light may be employed to give the desired lighting 
effect, and none but an expert can tell which kind it is. 
The whole j^roblem of satisfactory artificial lighting (given 
a steady unflickering light such as all modern illuminants 
are) is a matter of the proper disposition of the light with 
respect to the objects to be lighted, and with respect to the 
people who are to see these objects. 

A Very Importaxt Fuxdamextal. — The most fun- 
damental principle of good artificial lighting is that the light 
must shine on the object of interest but not in the eyes of the 
observer (Figs. 37 and 38) . All shades, globes, reflectors, 
and special arrangements of the light with respect to the 
walls and ceilings, if correctly conceived, should have this 
simple object constantly in view. Other features are to be 
sought as well, as is shown later, but this is the chief. Try, as 

101 



102 HYGIENE OF THE EYE 

an experiment, looking at a picture, first with an unshielded 
light alongside and a little in front, then with the light 




Fig. 37. — The wrong way to use a light. It shines in the workman's eyes and decreases his 
ability to see his work. The eye3 should never be exposed to an unshielded light source. 

shielded from the eyes, say with the hand. In one case the 
eyes are blinded with the light; in the other the picture is 



ARTIFICIAL LIGHTING 103 

clearly seen, although no more light falls on it than before. 
Light falling in the eyes instead of on the object is twice 
lost. 

Shades and Reflectors. — Never let an unshielded 




Fig. 38. — A good way to light a desk. The lamp is completely shielded from the worker's 
eyes by the opaque reflector, which at the same time throws a flood ot light on the desk. By 
placing the light to the left side the shadows tall correctly tor writing, and reflections from glossy 
paper surfaces are directed away from the eyes. A desk light alone is not sufficient for comfort, 
but should be supplemented by some general diffused illumination. 

light be visible. At the same time, the effort should be made 
to let a large part of the light fall on the object of interest — 
the book page, the sewing, the machine (Figs. 39 and 40) . 
To achieve this double object, shades and reflectors of vari- 
ous types are essential. A shade is in general a m'e re obstacle 



104 HYGIENE OF THE EYE 

or screen, interposed between the source of light and the 
eye. It may, for instance, be a cylinder of opaque or trans- 
lucent material about a table lamp, permitting the unob- 




FiG. 39. — The wrong way to use a table lamp. Dazzling reflected images of the light come 
from the book page and polished table top, and cannot be escaped by the reader in this position. 
This condition is almost but not quite as bad as though the lamp had no shade to prevent the 
light from shining directly into the eyes. Avoid fringes on lamp shades. Their wavering 
shadows are excessively trying to the eyes. 

structed light to go upward and downward, but not hori- 
zontally toward the eye. Or it may be a half cylinder in 
front of a wall bracket, permitting the light to go up- 



ARTIFICIAL LIGHTING 



105 



ward, downward and to the wall, but not straight out. A 
reflector differs from a mere shade in that its inner sur- 
face is highly reflecting, and so shaped as to direct the 




Fig. 40. — The correct way to use a table lamp. The table is provided witih a dull coveri 
and the book is held sideways to the light, which for reading may come from either side, or 
over either shoulder. No disturbing reflections reach the eyes. A table lamp alone is not 
sufficient light for a room, unless it has an open top which throws light to the ceiling and thus 
provides general diffused lighting to help out the locally intense illumination. 

light in a definite direction. Thus there are reflectors which 
concentrate the light over a small space, such as a desk 
top, and other reflectors which spread the light over large 



106 HYGIENE OF THE EYE 

areas, such as the floor of a room. Close, fine, difficult 
work will often call for the concentration of light given 
only by a properly selected reflector. A reflector is not 
necessarily a shade, but in all ordinary cases it should be. 
If the light source is not concealed by the reflector, or at 
least greatly reduced in brightness, for the normal posi- 
tion of the user of the light, it is not correctly designed. 

Large and Small Light Sources — Their Charac- 
teristics. — A simple but useful way to classify artificial 
light sources is by size. We have light sources of small 
area, such as an incandescent electric lamp filament, or a 
gas mantle. We have light sources of large area, such as 
an illuminated ceiling or side- wall, either of which serves 
as the real illuminator of the room, even though the light 
originally comes from, a small point-like source. 

The illuminations due to these two classes of light 
sources are called respectively directed and diffused illu- 
mination or lighting. By directed light we get sharply 
defined shadows. By difi'used light the shadows become 
indefinite or soft, and can even be practically missing, if 
the source of difl*used light be large enough. Each kind 
of lighting has its place. Directed lighting, with its defi- 
nite shadows, is adapted to places where differences in the 
relief of various parts must be readily appreciated, as in 
type setting, some kinds of sewing, and other localized 
work, especially if the light falls somewhat from the side. 
Diffused lighting, with its absence of contrasting illumi- 
nated and shadowed spots, is adapted to large spaces where 
all parts should have some light — to general rather than 
localized activities. It goes around corners and lights 
those places which a directed light would leave in objec- 
tionable obscurity. 



ARTIFICIAL LIGHTING 107 

The diif erence in the kind of illumination provided by 
large and small light sources is not the only important 
difference between them. A large area light source is 
much less annoying to look at than a small one of the same 
light giving power. True it is that the light source should 
never be looked at, but it often happens that it obtrudes 
itself into the field of vision in a way that cannot be entirely 
avoided. For instance, where work is being done on pol- 
ished metalware , many bright surfaces reflect the light 
source to the eyes, in practically undiminished brilliancy. 
In such cases the only relief — and it is only partial at 
that — is to spread out the light source as much as possible, 
thereby making it less brilliant, and so less irritating. This 
can be done by covering the light with an opal or milk 
glass, by frosting the lamp bulb, if it is an electric light, 
or by directing the light upon a large dull white surface — 
the wall or the ceiling — which then becomes the light 
source. 

All modern light sources are too bright to be looked at 
directly, and in order to minimize the dangers due to their 
being accidentally seen they should be spread out by dif- 
fusing surfaces as much as is compatible with the kind 
of work for which they are to be used. Usually even 
where directed light is essential the electric lamp filament 
or gas mantle can be enclosed in a diffusing device, such 
as a frosted or opal globe or reflector, which will enor- 
mously reduce its annoying character if directly viewed, but 
will at the same time leave it small enough to give the 
necessary relief -revealing shadows. 

Contrasts to be Avoided. — Beside the question of the 
actual brightness of a light, which has just been discussed, 
is the question of the contrast it makes with its background 



108 HYGIENE OF THE EYE 

or surroundings. If a gas mantle is viewed against the 
bright sky in the day-time it is so little different in bright- 
ness that it causes no discomfort. But against the black 
night sky it is well nigh unbearable. This illustrates the 
importance of preventing big contrasts between either the 
lighting devices and their backgrounds, or between the light 
and dark parts of the field of view. No light source — by 
which is here meant the entire lighting device as seen, 
shade or reflector and all — should be in such contrast with 
its immediate surroundings that these may not be looked 
at in entire comfort at the same time as the light. A bare 
electric lamp in a wall bracket on a dark wood panelled 
wall forms a contrast to which the eye should never be 
subjected. The various illuminated objects in a room 
should never be so different in brightness that the eye is 
strained in attempting to look from one to another, or 
must wait a perceptible period to become adapted, as it is 
called. The practice of working at a table brightly illumi- 
nated by a lamp which is the only light in the room is to 
be condemned for this reason. On looking away from the 
table the eye practically falls over a light precipice. 

The Direction of Lighting. — Entirely satisfactory 
lighting is not merely a question of avoiding irritating or 
annoying conditions. The illuminated room must be pleas- 
ing in appearance — it must appeal to the esthetic sense, 
and to our accustomed ideas of fitness. Probably nothing 
contributes more to this aspect of lighting than the direc- 
tion from which the light comes, and the part of the room 
on which the major part of the light falls. The commonest 
arrangement of lighting fixtures is that which makes the 
light come from directly ahove, but this is probably the 
least pleasing direction of all. Shadows then fall directly 



ARTIFICIAL LIGHTING 



109 



downward, resulting in a loss of our power to properly 
appreciate the sizes and positions of objects. Artists have 
long recognized that nature looks its best when lighted by 
the rising or the setting sun, and looks its worst when the 
sun beats straight down. For the same reason that a tree 




Fig. 41. — Dark walls waste light and prevent diffusion. These two booths are illumi- 
nated by exactly the same light. In the one with light walls, all the details of the statue are 
illuminated; in the other the statue shows only by harsh contrasts. 

is a more pleasing sight when its shadow falls away to one 
side than when the shadow is a mere blotch about its root, 
so a room with a goodly share of its light striking across it 
is more satisfactory than if lighted solely from above 
(Fig. 41). 

For the best appearance of a room it is necessary to 



110 HYGIENE OF THE EYE 

yield in some degree to what we have become accustomed 
to by day, and to some of the characteristics of our furnish- 
ings which owe their origin to daylight conditions. Most 
daylighting of interiors is by windows facing the sun or 
sky. A very large amount of light falls from the window 
to the floor and on to comparatively dark floor coverings 
and furniture. If our room by night is not to look top- 
heavy and gloomy, it is desirable to throw a large amount 
of our artificial light to the floor and furniture. 

Yet another concession to our ingrained idea of fit- 
ness is to avoid concealing entirely the point of origin of 
the light. The light source is a centre of cheer and no 
mean part of the decorative makeup of the comfortable 
room. Where the lighting is entirely diffused, much of 
the life and coziness of the room is lost. But this natural 
yearning for an unmistakable centre of light radiation does 
not by any means call for a dazzling light shining in the 
eyes. It is quite sufficient for the shade or reflector sur- 
rounding the lamp to be a little brighter than its surround- 
ings in order to satisfy this psychological need. Chief 
dependence should be placed on the clear revealing of the 
direction from which the light comes, by the naturally 
greater illumination near the light source and by the direc- 
tion in which the shadows fall. 

The Most Satisfactory Arrangement of Lights. 
— ^In the nature of things there cannot be a standardized 
arrangement of lights to give the best effect, because every 
kind of room and every use to which a room is put makes 
different demands. But in general it may be said that the 
problem of satisfactory lighting — assuming that the neces- 
sary precautions as to concealing the light sources, avoid- 
ing contrasts, and so on, have been observed — reduces to 



ARTIFICIAL LIGHTING 111 

finding the proper balance between directed and diffused 
light, and between the amounts of light in the various 
parts of the room. Extremes are to be avoided. Thus 
entirely diffused lighting produces a dead, fog-like effect. 




Fig. 42. — A common type of fixture planned to give diffused illumination. The light 
source is in the opaque bowl which reflects the light rays upward to the ceiling. Used alone 
this type of fixture is apt to be inadequate, because the lower part of the room is deficient in 
light. It should be helped out either by pendent lamps to give downward directed light, or by 
table lamps. 

On the other hand, too exclusively directed a light is apt 
to result in violent contrasts of light and shadow (Figs. 
42, 43, and 44). 



112 HYGIENE OF THE EYE 

A safe rule is that there should be enough diiFused 
light, from illuminated walls and ceiling, so that all parts 
of the room can be clearly seen. To this add directed light 
at the points of interest — the work table, piano, or book 




Fig. 43. — Another type of fixture designed to give diffused illumination. A translucent 
bowl, forming with the ceiling, a large area light source. In a small room this type of light may 
suffice for both general illumination and for the work table or desk. If so used it should be 
placed high enough over the desk to be well out of the line of vision, or should be behind and to 
the left of the worker. 

page. The amount of this directed light will vary greatly 
according to the kind of room. In the dining-room a very 
considerable concentration of light on the table is permissi- 



ARTIFICIAL LIGHTING 



113 



ble and desirable. In the small living-room or library, 
rather strong local lighting makes for coziness. But in a 
public auditorium or ball-room all parts demand nearly 




Fig. 44. — A well-considered side-wall light. Bright lamps aj^uinst dark walls are all too 
common. In this floor standard the light is concealed by a large area, low brightness shade, 
which obscures it only from the direction of the room. In back the light falls on the white 
window curtains, which with the ceiling and floor serve as sources of diffused light. Directed 
light passing out beneath the shade illuminates book page or work. 



114 HYGIENE OF THE EYE 

the same amount of light, which may be accomphshed by a 
very high intensity of diffused light or by many well- 
distributed local directed lights. 

Lighting Fixtures.^ — The practical working out of 
the principles of lighting depends upon the placing of the 
piping or wiring outlets, and on the choice of lighting fix- 
tures. The ideal way is to plan the lighting with the house, 
keeping definitely in mind the use of each room, together 
with the kind of furniture and its arrangement. But more 
often than not the outlets are already in place when the 
future occupant of the room first sees it, and the whole 
problem becomes one of choosing fixtures to make the best 
use of the outlets provided. These are not always in the 
best places, and even if they have been properly placed on 
the expectation of a certain use for the room, they may not 
suit the use for which the room is later put. It is always a 
safe thing, and usually possible, to have additional base- 
board or other portable lamp connections installed. These 
permit the use of different forms of fixtures, according to 
the use to which the room is put or the taste of the 
occupant. 

Four types of lighting fixture are available, classified 
according to the mode of support, or the position they 
occupy in the room — ceiling fixtures, wall brackets, floor 
standards, and table lamps or " portables." In each of 
these forms examples are to be found planned to give en- 
tirely diffused, entirely directed, or mixed illumination. 
Where there are several outlets the proper balance can be 
secured by a combination of a diffused lighting fixture 
with directed ones. For instance, the diffused light may 
come from a ceiling fixture of the suspended bowl type, 
the directed from a table lamp or floor standard which 
may direct all its light downward, either of these alone 



ARTIFICIAL LIGHTING 115 

not being fully satisfactory. Where there is but one out- 
let a fixture to give both the diffused and the directed 
light should be chosen. Such, for instance, is a table lamp 
which not only sends light down to the table, but through 
its open top sends light to the ceiling to be there diffusely 
reflected to all parts of the room. 

A cardinal rule in the selection of lighting fixtures is 
that they should be chosen not because they look well as 
examples of metal and glass work by day, but for their 
appearance and performance at night when lighted. Artis- 
tic appearance is very desirable, but it should be in addi- 
tion to, not at the expense of, serviceability. 

Other Things Nearly as Important as the Lights 
Themselves. — ^Furniture and wall coverings are a vital 
part of the lighting scheme of the room. Dark walls ab- 
sorb light, thus demanding the use of more gas or elec- 
tricity to give adequate illumination. But more serious 
than the loss of light caused by dark walls or ceiling is 
the fact that with them it is almost impossible to obtain 
an adequate amount of diffused light, or to avoid exces- 
sive contrasts between lighted and unlighted objects. 
Walls, and especially ceilings, should be light. Dark wood 
wall panelling, and carved wood ceilings, which we copy 
from our Elizabethan ancestors who lived mostly by day- 
light, are practically incompatible with efficient or com- 
fortable artificial lighting. 

Glossy surfaces should be carefully avoided in the fur- 
niture or objects used in a room. A polished table top, or 
one covered with a glass plate, reflects the unshielded light 
of the table lamp or overhead fixture directly into the eyes, 
and is just as bad as never-to-be-faced Tmconcealed light. 
Books or magazines printed on glossy paper are to be 
shunned for this same reason. Fortunately publishers are 



116 HYGIENE OF THE EYE 

being brought to a realization of the evil effects on eye- 
sight of glazed paper reflections, so that this souixe of 
glare may before long be done away with. 

Another thing nearly as important as the placing of 
the lights is the position of the occupant of the room. Even 
in rooms where the lights are poorly arranged it is often 
possible for a person to so place himself that the annoying 
lights are no longer seen. So too, in reading or writing, 
such disturbing reflections as may come from paper or 
table top can be escaped by having the light come from 
the side or over the shoulder. A safe rule is never to face 
the point from which the light comes. 

Finally, let it be remembered that if the lighting seems 
unsatisfactory it may mean nothing more than that the 
eyes have become tired from their day's work before the 
artificial light is used at all. The remedy may lie in the 
hands of the oculist instead of the lighting expert. 

Quantity or Light. — The quantity of light to be 
provided for is one of the first things considered by the 
illuminating engineer. It should be about the last thing 
for the layman to attempt to make a judgment upon. 
This is because the layman is altogether too apt to be led 
astray by any one of half a dozen other defects of a light- 
ing system, which must first be removed before it is possi- 
ble to decide whether the amount of light is sufficient. 
Never conclude that more light is needed until every light 
now used is properly shielded, until all excessive contrasts 
have been remedied, until all glossy reflections have been 
done away with. If then there is difficulty in seeing well 
enough for the work in hand, the lighting units may be 
increased in size, or more added. It is quite futile to at- 
tempt to improve the lighting by adding more light if every 
addition of light adds an equal amount of glare. 



CHAPTER VIII 

DAYLIGHT ILLUMINATION OF ROOMS AND 
BUILDINGS FROM AN ARCHITECTURAL 
STANDPOINT 

By William Copelaxd Furber 
architect axd consulting engineer^ phila.^ pa. 
As a civilized man spends, in all probability, consider- 
ably more than one-half of his time " under cover," the 
lighting of buildings, both natural and artificial, as an eco- 
nomic factor, has not, until quite recently, been fully recog- 
nized. This is undoubtedly due to the fact that the study 
of lighting systems has not been considered apart from 
utilitarian, structural, or architectural considerations. 

Artificial Lighting. — The introduction of artificial 
lighting units of great intensity, such as the arc light, and 
the high powered incandescent electric and gas lamp, was 
probably the determining consideration in the study of 
methods whereby the intensity of light could be mellowed 
by equitable diffusion, and in the last few years the inves- 
tigations along this line have been productive of far-reach- 
ing results in the artificial lighting of buildings. It seems 
remarkable in looking back over the crude and unsuccessful 
attempts at lighting which were prevalent in the quite re- 
cent past that devices for diffusing artificial light were not 
devised long ago. The possibility of simulating daylight 
by artificial means, and particularly in such parts of build- 
ings as it is not possible or desirable to introduce natural 
light, such as large areas below pavement levels, floor areas 
not adjacent to windows, and in auditoriums where exter- 

117 



118 HYGIENE OF THE EYE 

nal sounds had to be eliminated, has profoundly modified 
the design of buildings and has reduced to almost a negli- 
gible degree the dependence upon natural light. 

With the perfection of mechanical apparatus for sup- 
plying sweet, clean, washed and humidified air to any part 
of the building, and with the mechanical methods of ex- 
hausting vitiated air, the problem of the architect has been 
greatly altered, so that to-day large rooms and floor areas 
can be successfully lighted and ventilated without regard 
to their local environment ; as exemplified in the best types 
of the modern auditorium, in the commodious basements 
of the large department stores of the best class, and in the 
underground rooms of large metropolitan hotels devoted 
to restaurants, kitchens, etc. 

In another chapter of this book, the evil effects upon 
the structure of the eyeball, due to the concentration of 
the vision of young children upon the printed page, is 
touched upon and this fact should be brought home to the 
educational authorities in such a way that the daylight 
illumination of school-rooms and the effects of reflection 
from the side- walls will be more carefully considered, and 
the best methods employed to conserve the eyesight, than 
is at present possible under the existing rules. The eye- 
sight of children and teachers during school careers de- 
teriorates rapidly, because of the great injury that 
frequently results from the improper lighting of the school- 
rooms. 

School-rooms must be illuminated in such a way as to 
exclude all the effects of glare. The problem of glare has 
been investigated and the maximum hygienic value for illu- 
minants has been found to be approximately two and one- 
half candles for each square inch of illuminated surface; 
that is, no source of illumination, either direct or indirect. 



DAYLIGHT ILLUMINATION 119 

should exceed this value of two and one-half candles per 
square inch of space. It must also be remembered that the 
impression of glare upon the eyes from the source of light 
depends very greatly upon the background against which 
it is seen. A glowing illuminant without a shade, or an 
incandescent mantel or filament without a protector seen 
against dark velvet, will be very much more trying to the 
eyes than will the same source of light with a white paper 
behind it. All these evils of glare, however, can be over- 
come by the substitution of indirect lighting on the ceil- 
ings of such school and other rooms. 

The intensity, amount and distribution of artificial 
light and its effect upon the color values of rooms and 
their contents, have been studied according to scientific 
methods and the results of these studies are available for 
the student, so that a mere reference to them in this paper 
must be sufficient. 

Natural Lighting. — In the design of buildings, we 
all know, of course, that architectural design in tropical 
countries has led to the use of large wall spaces and small 
window openings, while in the high latitudes the converse 
is true, and architectural forms have been developed in 
which the glass surface occupies a large proportion of the 
wall surface, as exemplified in the Tudor and Elizabethan 
types, but these influences have not yet seriously affected 
commercial architectural design, excepting in several 
classes of buildings, notably factory and school buildings. 

In the construction of factory buildings, the recogni- 
tion of the desirability and necessity for an abundance of 
daylight has fortunately been rendered esisy of accom- 
plishment by fundamental changes in the structural de- 
sign of buildings, and by the invention of what is known as 
steel sash. In the design of such buildings, the substitu- 



120 HYGIENE OF THE EYE 

tion of structural framework of steel or reinforced concrete 
for masonry walls and piers, has rendered easily possible, 
the utilization of large areas of external walls for window 
openings, which were formerly required for structural sup- 
port, and as a result of the utilization of these two agencies, 
the external walls of factory buildings to-day consist of 
from fifty to ninety per cent, of glass, and of these two 
agencies, the steel sash has probably done more toward 
this desirable end than the latent possibilities of skeleton 
construction alone. 

In the design of school buildings, the usual modern re- 
quirement that the window area shall not be less than 
twenty per cent, of the floor area has markedly affected 
the architectural treatment of such educational buildings, 
and the further requirement of unilateral lighting, which 
is gradually being insisted upon as the only correct method 
of lighting school-rooms, is having a salutary effect also in 
the design of such buildings. In some States, the educa- 
tional authorities permit light at both the sides and rear 
of the room, in entire disregard of the detrimental effect 
of such a method of lighting on the eyes of the teacher, who 
is compelled to work facing the light. It is to be hoped 
that the requirements for lighting all school-rooms will 
soon insist upon unilateral lighting alone. It should be 
understood, of course, that this requirement for unilateral 
lighting does not prohibit skylighting in the ceiling where 
conditions render this desirable form of lighting possible. 
The lighting of school-rooms has not yet been given the 
attention that its importance demands (Fig. 45). 

In fixing the ratio of window area to floor space in 
school buildings, the State Boards of Education should 
take into consideration the exposure of the windows, for 
the value of the light admitted to the room is determined, 



DAYLIGHT ILLUMINATION 



121 



IP 






t^ 



m=t 



Zar:*^I£: 









:t_-t_^-=tr 



__1 




Fig. 45. — Proposed high school building. 



n2 HYGIENE OF THE EYE 

of course, very largely by the character of the environment. 
In city streets with high buildings adjacent, the amount 
of light admitted to the school-room is necessarily very 
much less than in the open country where there is no ob- 
struction to the light from the sky. The orientation of 
the rooms also is not usually considered. In fixing the 
ratio of window areas, it should also be remembered that 
rooms with a southerly exposure necessarily receive more 
light than those with a northerly exposure, and there is 
no proper excuse for a failure to recognize this important 
diiFerence in prescribing the requirements for the lighting 
of such buildings. If a twenty per cent, ratio was needed 
on the south side, considerable more is needed on the north 
side, and over and beyond the requirements for daylight, 
the hygienic value of sunlight should be given due recogni- 
tion, which would result in penalizing northern exposures. 
If the State Boards of Education favored the southern 
exposure in some such way, more consideration would be 
given to the selection of school sites than is now ordinarily 
the case. While north light is to be preferred for many 
occupations where sunlight is not permissible, this consid- 
eration does not apply to school-rooms. In many instances, 
however, the local environment does not permit the admis- 
sion of a sufficient amount of light, under which condition 
a resort to a mechanical means for overcoming this defi- 
ciency is necessary, and prismatic glass can be used. 

The great value of prismatic glass in the lighting of 
school-rooms has not yet received proper recognition from 
the educational authorities who prescribe the requirements 
for school buildings, or has its value yet been recognized 
by many owners of factory buildings, workrooms, etc. 
The prismatic glass is simply window glass cast with hori- 
zontal prisms on the outer surface, which reflects the light 



DAYLIGHT ILLUMINATION 



123 




FiQ. 46. — Showing the use of prism glass to deflect the light in a horizontal direction. 



124 



HYGIENE OF THE EYE 



from the sky into the building. These prisms can be cast 
at various angles, which throw the light in a particular 
direction, depending upon the angle of its reflecting sur- 
face to the sky (Figs. 46 and 47) . 

The prismatic glass is made with prisms set at diff er- 



3K 



60' 



y^ 



y 






S5X 



// 



/: / 



(Ky Kxrc do* 



o 
o. 
a- 


c 



<r\ 

c 



Fig. 47. — Illustrating the uses of prism glass with different angles of reflection. 

ent angles, so that by the proper employment of glass with 
differing angles, the light can be thrown to almost any 
section of the upper part of the room. Prismatic glass 
has the great advantage of being able to make available a 
light from the sky, which is not possible without its use, 
and it has a particular advantage in buildings which do not 



DAYLIGHT ILLUMINATION 125 

receive their light from points near the horizon. If school 
windows with northern exposures were required to have 
the upper part of the sash filled with prismatic glass, it 
would go far towards overcoming the disadvantage of this 
orientation. 

What is true of school buildings is also true of manu- 
facturing buildings, although in certain lines of work where 
shadows are inadmissible and where the intensity of the 
light should not vary greatly during the working hours, 
southern exposures are not permissible. In textile trades 
in the matching of color values, in engraving, in artists' 
studios, etc., and in all work where close vision is required, 
the northern light is to be preferred, and where conditions 
permit, this form of lighting can be accomplished by means 
of saw-tooth skylights, in which the vertical glass surface 
of the skylight is only open to the light from the north. 

In many buildings where north light is not required, 
the employment of skylights which have either a glass 
deck or a solid deck with glass side lights, permits a more 
equitable lighting of such rooms than can be obtained by 
windows alone. Such methods of lighting have utilitarian 
as well as architectural and aesthetic values. The simula- 
tion of skylights in the ceiling of rooms, by means of arti- 
ficial lights placed behind the diffusing sash, has been 
successfully carried out in a number of rooms, such as 
auditoriums, restaurants, etc., where the structural condi- 
tions prohibited the employment of actual skylights. By 
this means it is quite possible to give an underground room 
all the appearance and atmosphere it would have, were its 
roof opening to the sky. The Auditorium of the Asso- 
ciated Engineering Society's Building, and the Orangery 
of the Hotel Astor, in New York, are excellent examples 
of this method of artificial skylighting. 



126 HYGIENE OF THE EYE 

A considerable amount of direct light from the sky in 
top floors of buildings is not utilized, owing to a prevalent 
idea that a skylight cannot be made watertight. It is quite 
possible to make any skylight that is properly constructed 
and designed as tight as a solid roof, and a knowledge of 
this fact should lead to a larger use of skylights than is now 
the custom. There is no light equal to daylight, and every 
legitimate means of extending its use indoors should be 
utilized. 

Another method of introducing natural light into dark 
interiors is by the employment of prismatic vault lights 
set in the surface of pavements. With glass reflecting 
prisms properly placed, it is quite possible to reflect a con- 
siderable amount of light from the sky to the ceilings of 
basement rooms. 

Proper illumination, both natural and artificial, has a 
distinct commercial value on the output of work. In the 
first report of the Departmental Committee on " Lighting 
in Factories and Workshops," recently published in Lon- 
don, some startling facts have been shown. For instance, 
in testing the strength of the illumination in a workshop on 
a well-lighted top floor, they found it was only 2 to 10 
per cent, of the direct sunshine. In other words, workers, 
in what would ordinarily be considered favorable condi- 
tions, were losing 90 to 98 per cent, of the light. No won- 
der that eye-strain and headaches are common among 
indoor workers. It has been found, as a matter of fact, 
that spectacles are much more commonly used among them 
than among outdoor workers. Much can be done by the 
improvements in the system of lighting. In one case, the 
Committee found, on investigating a workshop where a 
better system of lighting had been installed, that the pro- 
duction had increased 10 per cent. 



CHAPTER IX 

DISEASES OF THE CONJUNCTIVA 

In the chapter dealing with the anatomy of the eye, the 
conjunctiva was described as the delicate membrane which 
lined the lids and covered the exposed portion of the eye- 
ball, and was continuous, through the medium of the lachry- 
mal passages, with a similar membrane in the nose. This 
membrane contains many glands, rich in mucus, and a 
plentiful supply of blood-vessels and nerves. When the lids 
are closed, it forms a closed sac, and at all times offers a 
favorable soil for the growth and development of micro- 
organisms, the germs of disease. These microorganisms 
are very minute vegetable organisms, which multiply with 
great rapidity when they are placed under conditions favor- 
able to their growth, and in the process of growing, destroy 
the tissues in w^hich they develop. 

In the case of the conjunctiva, they excite a secretion 
which varies in character according to the intensity of the 
inflammation occasioned by the bacillus or microorganism, 
the product of the most virulent being a thick yellow dis- 
charge termed pus, while the milder growths occasion a 
thick mucoid or catarrhal exudation. The discharges from 
the conjunctiva excited by these small agents are all con- 
tagious, that is to say, they have the power of exciting a 
similar inflammation in other eyes with which they maj^ 
come in contact. The degree of the contagiousness is in 
direct ratio with the virulence of the organism, being great- 
est in purulent conjunctivitis and least in the catarrhal 
forms. The term conjunctivitis is applied to all forms of 

127 



128 HYGIENE OF THE EYE 

inflammations of the conjunctiva, the particular varieties 
being designated by a descriptive prefix, such as catarrhal 
conjunctivitis, purulent conjunctivitis, etc. 

Infection of the eyes of an individual from those of an- 
other is occasioned by the conveyance of the germs, either 
by bringing them from the affected eye into direct contact 
with the unaffected eye through the medium of soiled 
fingers or articles contaminated by the discharge from the 
the former, or through the medium of the air, the wind 
blowing the dried secretion from diseased into healthy eyes. 
The former mode of infection obtains in the purulent form, 
the latter in the milder or catarrhal forms. This peculi- 
arity of the manner of distribution of the disease accounts 
for the epidemic form which is frequently observed in 
connection with the catarrhal forms of conjunctivitis, while 
the more virulent types, unless propagated under unusu- 
ally bad hygienic conditions such as sometimes obtain in 
trachoma cases, generally occur singly. 

Not all forms of conjunctivitis are dependent upon 
germ activity. Uncorrected error of refraction is a potent 
cause of a mild form of conjunctivitis, the inflammation in 
the mucous membrane resisting all local treatment until 
the proper correcting lenses have been prescribed. Simple 
catarrhal conditions may also accompany inflammation of 
surrounding structures and may be excited by the action 
of irritants, such as small foreign bodies, the exposure of 
the eyes to high winds, smoke, certain fumes and gases, and 
heat and light rays. Workers over furnaces in iron 
foundries frequently have injected conjunctivae, and ex- 
posure to the sun rays or snow fields may excite a most 
distressing conjunctivitis, unless the eyes be properly cor- 
rected by some form of protecting glasses, containing lenses 



DISEASES OF THE CONJUNCTIVA 129 

properly colored to neutralize the irritating effect of the 
ultra-violet rays. Greenish and amber tinted lenses have 
been found to be best for this purpose. The conjunc- 
tiva may also be inflamed in consequence of certain diseases 
of the general system, which germinate poisonous prod- 
ucts which may eliminate themselves from the broad ex- 
panse of the conjunctival mucous membrane. 

Diseases of the conjunctiva, therefore, are among the 
most common affecting the eye, and occur under a variety 
of forms. It would be apart from the purpose of this book 
to describe all, though a detailed account must be given of 
several, as they are of paramount importance, and their 
danger and frequency demand a fuller knowledge of them 
by the laity. 

Purulent Conjunctivitis of Infants — ^^Ophthal- 
MiA Neonatorum. — Under these names are included all 
inflammatory conditions of the conjunctiva of the new- 
born babe, conditions which by reason of their malignancy 
are responsible for at least 25 per cent, of the blindness 
throughout the world. As it will presently appear that 
this disease is almost always preventable and its frequency 
due to ignorance and incompetency, which can only be com- 
bated by a campaign of instruction, the consideration of 
this subject will be treated at length, not only as regards 
its recognition and prevention, but also as to its treatment. 

This inflammation of the conjunctiva appears usually 
on or before the fifth day after birth, as a redness and 
swelling of the lids, and with an attendant discharge of 
watery fluid from between the lids. The redness and swell- 
ing of the lids rapidly increase and the discharge becomes 
thicker and more copious, so that on the third or fourth 
day after the appearance of the inflammation the lids are 



130 



HYGIENE OF THE EYE 



so swollen that they can be forced apart only with diffi- 
culty, while the lids and the eyeball are covered with a 
thick creamy pus (Fig. 48). If untreated, the intensity 
of the inflammation irritates the cornea and this membrane 
loses its transparency and becomes infiltrated with pus. 
After a time, the cornea, weakened by its ulceration, per- 
forates, and the fluids within the eye and often the lens 
escape into the conjunctival sac and the eye is lost (Fig. 




Pig. 48. — Negro baby with ophthalmia neonatorum. 

49 ) . Although but one eye is usually afl'ected primarily, 
unless the greatest care is exercised the other soon becomes 
similarly involved. After the disease has run an acute 
course of several weeks, the inflammatorj^ symptoms gradu- 
ally subside, and after a time the lids are opened again, but 
over sightless and hideous stumps, instead of seeing eyes 
(Fig. 50) . As years go by, not infrequently, the sightless 
globes stretch and the transparency of the cornea being 



DISEASES OF THE CONJUNCTIVA 



131 



replaced by glistening white scar tissue, the deformed and 
sightless orbs, rotated by their poor little possessors from 




K... 



Fig. 49. — Corneal abscess with perforation. 



side to side in their search for vision, form as striking and 
distressing a picture as may be found in nature. 

The disease is very contagious, and if the discharge 
enter the eyes of an adult or older child, an inflammation 




Fig. 50. — Opaque cornea after ophthalmia neonatorum. 

of even greater seriousness is excited than that which pri- 
marily affected the eyes of the new-born babe. 

The cause of this distressing disease is the infection of 



132 HYGIENE OF THE EYE 

the eyes of the child during the passage of the head through 
the birth canal of an infected mother, or by the entrance 
of the germs into the eyes shortly after birth, in conse- 
quence of carelessness upon the part of attending phy- 
sician, midwife, or nurse. The germ usually responsible 
is the pus of gonorrhoea, a disease which affects the genital 
organs of both men and women, and is readily transmis- 
sible from the one to the other. The history obtainable in 
many cases is that of the mother infected by her husband, 
who, though once diseased with gonorrhoea, had dared to 
marry, as the absence of urethral discharge had encour- 
aged the idea that the affection was cured or had worn 
itself out. After marriage, the disease communicated to 
the wife in a mild form gives no indication of its existence 
until the child is born and the germs entering the closed 
sac of the conjunctiva propagate and destroy. Society 
should demand that every man who has suffered from 
gonorrhoea should debar himself from matrimony until he 
has been assured by expert examination that he is free 
from infection. 

Not all cases of inflamed eyes after birth, however, are 
due to venereal diseases, for germs of a totally different 
and less virulent nature may gain access to the conjunctiva 
and may occasion much the same symptoms as have been 
described.^ It is most unfair, therefore, to attach an op- 
probrium to the parents of all children with ophthalmia, 
and the finger of scorn has been shaken too often in the 
face of a perfectly innocent and virtuous father. 

As it is sometimes difficult to discriminate rapidly and 

^ It has been estimated! that gonococcus infection gives rise 
to about 60 per cent, of all cases of ophthalmia neonatorum. The 
pneumococcus is responsible for about 10 per cent. 



DISEASES OF THE CONJUNCTIVA 133 

easily between the milder and, so to speak, innocent type 
and the malignant form, it is customary^ to treat all cases 
from the beginning as though they were of venereal origin, 
for so rapid and virulent is the course of the conjunctivitis 
that unless proper and prompt treatment is applied, the 
eye is lost. Xo time can be wasted. Xo chances run. 

In 1881, Crede, a well-known Belgian physician, found 
that if a 2 per cent, solution of nitrate of silver be dropped 
into the eye of a child directly after birth, the pus germ 
producing ophthalmia neonatorum could be killed and the 
development of the disease prevented. This discovery has 
been of vital importance, and many a child has been saved 
from blindness by this simple procedure. Statistics show, 
for example, that in certain classes of cases the disease de- 
veloped in 10 per cent, of children in whom the silver solu- 
tion had not been used, and in but 0.17 per cent, after 
Crede's procedure had been applied. 

To eradicate the disease, it would appear therefore only 
necessary that the silver solution should be used in the eyes 
of all babies directly after birth. This apparently simple 
problem is not, however, so easy of solution, and there are 
various factors which experience has shown must be taken 
into consideration before urging the adoption of Crede's 
method in all cases. In the first place, the silver solution, 
even when properly applied, may excite considerable irri- 
tation of the mucous membrane of the eye, which, unless 
treated, might result in some permanent danger to what 
might otherwise have been an unaffected eye. Again, the 
hands instilling the drops may be clumsy or unclean, and 
healthy eyes ruined in consequence. ^lany ophthalmol- 
ogists, therefore, who have cared for eyes damaged in this 
way, are loath to urge the passage of laws making the 



134 HYGIENE OF THE EYE 

application of the Crede method obligatory in all cases, 
and incline to the recommendation of its use in all suspected 
cases and in all hospitals and institutions where the danger 
of infection is greater than in certain classes of private 
work. Yet it is very necessary that each State should have 
stringent laws and a well-defined and practical policy aim- 
ing at the control and actual elimination of ophthalmia 
neonatorum. Briefly outlined this should be as follows: 
1. Every birth should be reported to the Bureau of Health 
within 24 hours. 2. Every case of inflamed eyes should be 
reported to the Bureau of Health within 4 hours. 3. The 
provision by the Bureau of Health for skilled ophthalmic 
treatment of every reported case within two hours after 
the Bureau has been notified of the existence of the ocular 
disease, by the attending obstetrician or midwife. The 
bureau must exercise control over the treatment of the case 
until the ophthalmologist in attendance reports the eyes 
•entirely free from inflammation. When proper home 
treatment is for any reason undesirable or impossible, all 
the hospitals receiving financial aid from the common- 
wealth must be ready to provide indoor treatment for the 
child and mother as well if the need arise. 4. Solutions of 
silver nitrate for prevention should be distributed free 
upon request, and printed matter describing the dangers 
of ophthalmia neonatorum, with hints as to cleanliness 
itself, properly couched for the comprehension of the laity 
and printed in various languages, should be freely cir- 
culated. 5. The midwives who have charge of perhaps 
nearly one-half of the births in the United States should 
be licensed, and their recognition given only after they 
have received sufficient education to warrant their attend- 
ance of a woman in labor. They should receive thorough 



DISEASES OF THE CONJUNCTIVA 



135 



training in the washing out of a child's eyes and the in- 
stillation of the silver solution (Figs. 51, 52, and 53). 

The following directions to mothers, midwives, and 
nurses are freely distributed by the Department of Health 
of one of the great commonwealths of this country, and 




FiQ. 51. — A good midwife cares for the baby's eyes. Careless and untrained midwives are 
responsible for much infantile blindness. 

are so clearly expressed and graphic that they are printed 
in full. 

" This disease is always due to an infection entering the 
eyes of the baby at the time of or shortl}^ after birth. It 
may be prevented almost always by proper care and early 
and correct treatment. 

" If precautions are not taken, and the disease de- 



136 



HYGIENE OF THE EYE 



velops and runs its course unchecked, the sight is totally 
destroyed, often within a fortnight. 

" For All Mothers. — Pleasures to he Taken hy the 



a%4^ 




Fig. 52. — -Nurse applying drops to baby's eyes 



Mother During Pregnancy. — All women during preg- 
nancy should be instructed as follows: Daily external 
cleansing should be thoroughly performed with soap and 
water and a clean wash cloth. Should the pregnant woman 



DISEASES OF THE CONJUNCTIVA 



137 



have any irritating discharges, or even profuse white dis- 
charge, she should be instructed to immediately consult her 
physician or the nearest dispensary. 

"For All Children ( Prevextiox ) » — Care that 
Should he Given to the Child at Birth to Prevent Oph- 




Vin. .>i. — New-born baby being treated in hospital for babies' sore e> o^ 

thalmia Neonatorum. — Inmiediately after the delivery of 
the head, before the delivery of the body, the eyelids should 
be carefully cleaned by means of absorbent cotton or a 
soft linen cloth and dipped into warm water that has l>een 
boiled or boric acid (saturated) solution. A separate cloth 



138 HYGIENE OF THE EYE 

should be used for each eye, and the lids washed, from the 
nose outward, free from all mucus, blood or meconium. 
All wipes should be burned after using. No opening of 
the lids should be attempted. At this time also the lips 
and nose should be in like manner wiped free of mucus, and 
the little finger, wrapped with a piece of moist linen, should 
be passed into the child's mouth and any accumulated 
mucus removed by an outward sweep of the finger. As 
soon after birth as possible the eyelids should be again 
wiped clean of mucus, and two drops of a 1 per cent, solu- 
tion of nitrate of silver should be dropped into each eye. 
One application only of the silver solution should be made, 
and ordinarily no further attention should be given the 
eyes for several hours. 

" Each time that the child is bathed, the eyes should be 
first wiped clean, as above described, with the boric acid 
solution. The hands of the person charged with the care 
of the child must be washed with soap and dried with a 
clean towel before the eyes of the child are touched. Every- 
thing that is brought near the eyes of the child must be, in 
every instance, absolutely clean. 

" The cotton that is used on the eyes of the child must, 
in every instance, be immediately burned after it is used. 
The water, towels, old linen, and the cotton that have been 
used on the mother must, under no circumstances, be ap- 
plied to the child. The air of the bedroom must be kept as 
pure as possible, and the linen should never be dried in the 
sick room. 

'' What Must be Done When Inflammation of the Eyes 
Appears. — ^When the lids become red and swollen, and are 
gummed along their borders, and when mattery discharge 
is mixed with the tears as the child sleeps or cries an oculist 



DISEASES OF THE CONJUNCTIVA 139 

or a physician should be called immediately, or the child 
taken to the nearest dispensary. Each hour of delay adds 
to the danger. While waiting bathe the eyes of the child 
every half hour with pledgets of cotton dipped in a solu- 
tion of boric acid. Open the lids wide and allow the 
solution, which should be warm, to flood the eyes and wash 
out any matter which may have gathered there. 

" The child should not be fondled and nothing which 
has been used about the eyes or face should be used for 
any other purpose. All of those in the home should be 
warned of the danger of catching the disease by getting 
the matter into. their own eyes. Do not listen to those who 
say it will amount to nothing, or to those who say to bathe 
the eyes of the child with the mother's milk (the milk is a 
means of spreading the germs of this disease). Such ad- 
vice is bad; the delay may result in blindness." 

The prognosis in ophthalmia neonatorum depends en- 
tirely upon the progress which the disease has attained when 
the eyes come under the care of the ophthalmologist, for 
if the proper treatment be instituted within the first few 
days, before corneal involvement has occurred, the sight 
can, as a rule, be saved. If the cornea shows signs of ulcera- 
tion when expert medical supervision is sought, the out- 
look is much more serious and more or less loss of visual 
acuity is sure to follow. 

Purulent Conjunctivitis of Adults. — Gonorrhoea 
may also affect the eyes of adults, the pus germ being con- 
veyed to the eyes, as a rule, directly from the affected 
genitalia by soiled fingers. Others may also be infected 
by the germs being carried to their eyes by towels, hand- 
kerchiefs, bed linen, already contaminated by a person 
with gonorrhoea. The inflammation set up in the conjunc- 



140 HYGIENE OF THE EYE 

tiva under such conditions is most intense, giving rise to 
great swelling of the lids and of the mucous membrane. 
In consequence of the intensity of the inflammation, the 
cornea is involved, and perforation of this membrane, with 
loss of the eye, may occur within four or five days after the 
initial symptoms have manifested themselves. If but one 
eye is affected, the other usually follows unless the greatest 
care is exercised and the most vigorous treatment instituted. 

All attempts to successfully treat such cases as am- 
bulants are futile, and the author cannot remember to have 
seen one eye saved, unless the patient was confined to bed 
from the very first and received constant and skilful treat- 
ment until the danger had passed. 

The discharge from the conjunctiva, at first merely 
streaked with mucus, becomes thick and copious and is ex- 
tremely contagious. Attendants upon such cases must 
exercise the greatest care to avoid infection. All cotton or 
lint dressings should be burned and the hands of surgeons 
and nurses carefully sterilized after each application of 
drugs or dressings. If but one eye is affected, it is usually 
customary to protect the sound eye by means of a watch 
crystal plastered into position before the eye by adhesive 
plaster. This device serves not only as a protection, but 
also enables the surgeon to inspect the eye and permits 
the patient to have some view of his surroundings. 

So acute is the inflammation and so virulent its prog- 
ress that it has been estimated that but 50 per cent, of eyes 
so infected recover. The necessit}^ of prompt and active 
treatment in gonorrhoeal ophthalmia of adults must there- 
fore be apparent, and the strictest mandate to all those 
affected with sronorrhoea to observe the greatest caution 



DISEASES OF THE CONJUNCTIVA 141 

in all things and to seek medical aid on the first suspicion 
of an inflamed eye seems reasonable to comply with. 

Metastatic Gonorrhceal Ophthalmia. — In addi- 
tion to the direct invasion of the conjunctiva by means of 
soiled fingers, etc., the gonorrhoeal poison may also enter 
the eye indirectly, through the medium of the blood. 
Gonorrhoea does not always remain a localized disease of 
the genital organs, but in certain cases, especially those who 
are gouty or rheumatic, and those who have suffered from 
repeated attacks of the disease, the germs may enter the 
blood and involve other parts of the body. The joints 
especially show a marked predilection to participate in this 
form of general blood poisoning, and under the form of a 
general rheumatic infection, inflammatory conditions arise 
in them which are most persistent and frequently cripple 
the patient for life. 

Either as a part of this rheumatic process or partici- 
pating in a general blood infection without articular in- 
volvement, the eye tissues not rarely show involvement ; the 
iris, conjunctiva and cornea may all be inflamed, with a 
frequency of involvement of these tissues in the order 
named. 

These transmitted or " metastatic " inflammations, as 
they are called, are extremeh^ serious when the iris is in- 
volved, but less so in their corneal and conjunctival mani- 
festations. ^Metastatic gonorrhoeal conjunctivitis is much 
less dangerous to sight than the conjunctivitis caused by 
direct infection of the gonorrhoea germ. It usually takes 
the form of a persistent attack of inflammation of the 
membrane, with considerable swelling of the lids and con- 
junctiva and with a more or less copious mucopurulent 
discharge. Local treatment is ineffective, the inflamma- 



142 HYGIENE OF THE EYE 

tion yielding only after the poisonous nature of the internal 
secretion and the blood have been improved, and by treat- 
ment directed to the primary source of the inflammation. 

Women are rarely affected by metastatic gonorrhoea, 
but a form of purulent conjunctivitis is sometimes ob- 
served in young girls the subjects of vaginitis, the gono- 
cocci present in the discharge being conveyed to the eyes 
by the fingers or from soiled linen, etc. The resultant con- 
junctivitis is often quite violent, though rarely so severe 
as the gonorrhoeal conjunctivitis of adults. At times, in 
consequence of the contagious nature of the vaginitis, the 
genital affection in association with the conjunctivitis may 
assume an epidemic form in hospitals, schools and asylums. 
If properly treated, such cases usually recover without 
impairment of vision. 

Trachoma — Granular Conjunctivitis. — Next in 
importance to purulent conjunctivitis caused by the germ 
of gonorrhoea is granular conjunctivitis, or, as it is gen- 
erally termed, trachoma. This disease of the conjunctiva 
runs a prolonged course, affecting all parts of the mucous 
membrane, and is attended by the development of so-called 
granulations, or trachoma bodies, in consequence of which 
the conjunctiva loses its smooth surface and becomes rough- 
ened (trachoma, from the Greek " traxus," meaning 
rough) (Fig. 54). Later the granulations disintegrate 
and form scar tissue, causing distortion of the lids and 
lashes. In addition to the changes in the lids, vasculariza- 
tion and ulceration of the cornea follow, giving rise to 
marked impairment of vision and in some cases to total 
loss of sight. In most cases the disease is ushered in with 
symptoms similar to those of purulent conjunctivitis, the 
lids being swollen and inflamed and bathed in a copious 



DISEASES OF THE CONJUNCTIVA 



143 



discharge containing an admixture of mucus and pus ( Fig. 
55 ) . This acute stage may last for weeks or months, finally 
passing into a milder one of constant irritation and dis- 








Fig. 54. — -A typical case of advanced tra- 
choma ' showing numerous granulations. Lids 
hypertrophied. 



Fig. 55. — Kentucky girl suffering from 
trachoma, holding her eyes open with 
forefinger and thumb. 



charge. In other cases the advent of the disease is in- 
sidious (Figs. 5% and 57), the trachoma bodies developing 
with but little accompanying inflammation of the conjunc- 




FiG. 56. — Trachoma. Cicatrization 
marked. 



well 



Fig. 57. — Trachoma. Cicatrization almost 
complete. 



tiva. The lids, however, are thickened and droop, giving 
a characteristic sleepy appearance to eyes so aflTected. 
Upon the eversion of the lids in many of these less acute 



144 



HYGIENE OF THE EYE 



cases, the granulations may at first escape the attention 
of the observer, being hidden deep under the fold of con- 
junctiva of the upper lid. The course of the disease is 
essentially a chronic one, remissions and exacerbations 
being excited by the slightest extraneous causes, as well 
as by certain conditions of the system. Unless recog- 




FiG. 58. — The operation of rolling or expression. 

nized in its earliest stages and a cure assured by treatment 
(Fig. 58) directed over a long period, trachoma is un- 
curable, and all of the later forms of treatment are merely 
palliative. 

Trachoma is an ancient disease, reference to it being 
found in the earliest literature. Originating in the Far 



DISEASES OF THE CONJUNCTIVA 



145 



East, it was probably carried westward along the great 
caravan routes. Although doubtless present in Europe 
before that time, the spread of the disease over that coun- 
try is generally attributed to the return of the Napoleonic 
soldiers from Egypt to Europe, many of the troops 




Fig. 59. — Man and child using common towel. Trachoma and other intectious eye diseases 

contracted in this way. 

having contracted the disease in Egypt from the native 
population. 

Trachoma is very contagious, the infective material 
contained in the discharge being conveyed from eye to eye 
by dirty fingers, soiled towels (Fig. 59) and linen, and 
wash basins contaminated with the disease, etc. Trachoma 

10 



146 HYGIENE OF THE EYE 

is a disease of poverty, the conditions under which the very 
poor live fostering its development and spread. The mass- 
ing together of large numbers of people, children or 
adults, in badly ventilated houses, without the possibil- 
ity of maintaining personal cleanliness, is responsible 
for its rapid spread under such conditions. Hence it is 
that the Jews, by reason of their abject condition in so 
many parts of the world, but particularly in Russia and 
Poland, are so frequently affected. The disease is also 
common in Ireland and almost all the Southern Euro- 
pean nations. It is estimated that 90 per cent, of the 
population of Egypt is afflicted with the disease. It 
would appear that the negro race is practically immune 
from trachoma. 

Unfortunately, the disease is not uncommon in the 
United States, having been introduced largely by infected 
immigrants. Indeed, in 1897, the government found the 
spread of the disease from this source to be so great that a 
law was passed requiring the examination of the eyes of 
all immigrants and making mandatory the deportation of 
aliens so afflicted. Unfortunately, however, the bars were 
put up too late, for the disease had already gained con- 
siderable headway in certain parts of the country. The 
Jewish peddler and tailor and the Italian and Slavish 
laborer in mines and mills spread the disease, so that there 
is no part of the country where trachoma cannot be found. 
The greater number of cases from foreign infection are 
found, however, in the large maritime and manufacturing 
and mining sections. 

In addition to its spread among the foreign popula- 
tion, trachoma is also common among the American In- 
dians and the Appalachian Highlanders in the mountain 



DISEASES OF THE CONJUNCTIVA 147 

sections of Kentucky, Virginia, and West Virginia. There 
is evidence that the Indians and these mountaineers must 
have contracted the disease many years ago; just how, will 
doubtless always remain undetermined. Statistics show 
that of the 323,000 Indians in our own country fully 20 
per cent., or nearly 65,000, are infected. In Kentucky 
there are 33,000 cases. 

One of the greatest problems connected with trachoma 
is its occurrence and spread among the school children of 
our country. The children of infected foreigners attend 
the same schools as the children of the native population, 
and come in intimate contact with them in studies and 
games, handling the same objects, and, with shame be it 
said, using at times the same roller towel, one of the most 
dangerous methods of transmission of this as well as other 
diseases. 

In view of these facts, it is apparent that in addition 
to the suffering wrought by trachoma, the visual impair- 
ment resulting from it presents a problem of great economic 
significance. ]\Iany are blinded in consequence and become 
an absolute drag upon the State, while the earning capacity 
of others affected with the disease is at least one-fourth of 
that of ordinary individuals. 

The government has done much in recent years to abate 
the evil, for, in addition to the stringent examination of 
immigrants and the exclusion of all affected with trachoma, 
the Public Health Service has been active in its efforts to 
eradicate the disease among the Indians and is aiding some 
of the States in their campaign against it. Already five 
completely equipped trachoma hospitals have been erected 
in the heart of the most seriously infected regions in 
Kentucky. 



148 HYGIENE OF THE EYE 

The prevention of trachoma, however, demands a more 
thorough knowledge by the public of its nature and dan- 
ger, and an improvement in the industrial and housing 
conditions of the poor. The report of every case to the 
proper health authorities must be mandatory, and each 
State must provide proper facilities for the isolation and 
treatment of all infected individuals until the danger of 
contagion is past. The eyes of all school children must be 
examined by properly trained individuals periodically, and 
arrangement should be made for the inspection of the eyes 
of all groups of adults, in whom there is likelihood of the 
existence of trachoma. 

The problem of controlling the disease among children 
is best met by their isolation in hospital schools, until they 
are absolutely cured of the disease. In order that this may 
be accomplished, a year or more in residence is often neces- 
sary, so that it is desirable to add to their ocular treatment 
instruction in elemental educational subjects, so that the 
period of their confinement for medical treatment may en- 
tail no period of mental inactivity. The care of adults 
affected with trachoma is much more difficult of solution, 
for it is manifestly impossible to isolate the beads of 
families, their sources of support, for any considerable 
time. In establishments employing large numbers of work- 
men, it is often possible to group all trachoma subjects to- 
gether and to keep them under constant medical supervi- 
sion, but in factories and mines employing fewer men this 
is not feasible, and the makeshift of medical care while the 
disease is absolutely disabling and the continuance of work 
after the ocular condition has been improved under social 
service or some other form of supervision, must be adopted. 
Placards of a warning and instructive nature concerning 



DISEASES OF THE CONJUNCTIVA 149 

the danger of the disease and the best means of avoiding 
it should be hung in conspicuous places, and friendly ad- 
vice and counsel given to the workers in their own lan- 
guage by some trustworthy and interested person. The 
following is an example of what such placards should 
contain : 

'' How to Avoid Contracting Trachoma, — Keep in good 
physical condition. 

Have large windows in your homes, which will admit 
plenty of fresh air and sunshine. 

Sleep with your windows open, even in winter, and keep 
the room well aired where you live and study. 

Wash your face and hands several times a day and keep 
the finger-nails clean. 

Never touch your face with your hands, unless they are 
absolutely clean. 

Do not use the family towel, especially in homes where 
there are cases of trachoma. 

Have your own towel and handkerchief, and don't let 
any one else use them. 

Boil your handkerchiefs before adding them to the 
wash. 

Do not allow your clothing or bedclothes to become 
soiled with the discharges (pus) from your eyes. 

When your eyes are discharging pus collect the dis- 
charges on cloths which can be burned, and stay away from 
other members of your family as much as possible. 

Always make sure that the wash basin is clean before 
using it. 

Do not sleep with persons having sore eyes, nor use 
bedclothes that have been used bv them. 



150 HYGIENE OF THE EYE 

Do not wear the clothing of others, nor use then* eating 
utensils without previously cleaning. 

Advise any one with sore eyes to have them treated at 
once. 

If the eyes become inflamed, apply at once for treat- 
ment to the nearest hospital, dispensary or to your own 
physician. 

Follow the directions of the doctors and nurses as to 
treatment and prevention." 

Although trachoma in its advanced stages is easy of 
detection, the determination of its existence in the earliest 
stages is often difficult and can only be made by physicians 
who have received special ophthalmic training. A number 
of diseases of the conjunctiva may be mistaken for it, and 
as these are harmless, the insistence upon the rigorous quar- 
antine just mentioned would entail unnecessary and un- 
just hardship upon the individuals whose eyes are so 
affected. The disease of the conjunctiva with which 
trachoma is usually confused is follicular conjunctivitis, 
for in this disease the conjunctiva is similarly studded with 
numerous granules or follicles. This condition, which oc- 
curs for the most part in underfed and so-called " scrof- 
ulous " children, may persist for months, without giving 
rise to any secretion from the conjunctiva or corneal in- 
volvement. It frequently disappears without leaving a 
trace under better hygienic conditions, and at no time in 
its course does it possess any contagious qualities. 

It is apparent, therefore, that the examination of eyes 
for the detection of trachoma, whether it be under the 
auspices of the government in its inspection of immigi^ants, 
or of school authorities, is valueless unless made by thor- 



DISEASES OF THE CONJUNCTIVA 151 

oughly trained medical graduates. All other examinations 
are misleading and valueless.^ 

Milder Forms of Conjunctivitis. — Acute Catarrhal 
Conjunctivitis; Pink Eye, — This form of conjunctivitis, 
occurring usually in the spring and autumn, when the 
weather is changeable and the winds high, is the most com- 
mon variety of conjunctivitis in the United States. It is 
very contagious, the contagion-bearer, the Koch- Weeks 
bacillus, the specific organism which causes the disease, being 
contained in the copious discharge from the conjunctiva, 
and communicated to the eyes of others not affected in the 
manner described in connection with the two preceding con- 
ditions. The inflammation, which at first occasions but a 
slight redness of the lids and eyeball, and an increase in the 
flow of tears, attains considerable severity by the third day, 
the lids becoming markedly swollen and the discharge thick 
and ropy. If but one eye is originally afl'ected, the other 
soon follows. Ordinarily the inflammation runs its course 
in about 10 to 14 days, the eyes making a complete re- 
covery. Corneal ulceration occurs at times, however, .so 
that the disease demands constant oversight and intelligent 
treatment. One of the synonyms of the disease, viz., epi- 
demic conjunctival catarrh, illustrates a pronounced ten- 
dency of the disease, the inflammation frequently spread- 
ing to all members of a household. Epidemics of the 
disease are of not rare occurrence in schools, asylums and 
similar institutions. 

Subacute Conjunctivitis, — As indicated bv the name. 



^ For a more detailed account of trachoma from a popular 
standpoint, the reader is referred to the excellent mionograph on 
trachoma, published by the National Committee for the Preven- 
tion of Blindness, 130 East 22nd St., New York. 



15!^ HYGIENE OE THE EYE 

the inflammation in this form of conjunctivitis rareh^ as- 
sumes the activity of that observed in the foregoing, but, 
unless properly treated, often runs a protracted course. 
The inflammation shows a predilection for the inner and 
outer angles of the lids, in consequence of which the term 
angular conjunctivitis is often applied to it. The secre- 
tion is usually scanty and has a tendency to accumulate and 
adhere to the inner angle of the eye. At times, however, 
the discharge is copious and may assume a mucopurulent 
type. Corneal ulcerations may also arise, threatening the 
loss of the eye. The disease may occur at any season of the 
year, and both eyes are generally affected. This form of 
conjunctivitis has been found to be due to a definite organ- 
ism, which was isolated and described by Morax and Axen- 
feld, two distinguished foreign ophthalmologists. 

Other forms of conjunctivitis due to other germs, such 
as the pneumococcus and influenza bacillus, are also com- 
monly met with. While the simpler forms of conjunc- 
tivitis may often be cured by the removal of the cause and 
the repeated cleansing of the eyes by boracic acid solutions 
and the application of cold compresses, those due to specific 
organisms demand skilled treatment. The milder forms 
of conjunctivitis, though ordinarily benign processes of the 
mucous membrane, may lead to the loss of the eye by 
corneal ulceration. Furthermore, the recognition of the 
microorganism causing the disease, and the application of 
the proper treatment, will often so modify its course that 
complete relief may be obtained in a few days from symp- 
toms which might often be disabling for weeks. A few 
applications of a solution containing zinc, to a conjunctiva 
inflamed by the Morax- Axenfeld bacillus, will often alle- 
viate as though by magic an inflammation which had resisted 
all other forms of treatment for a very long time. 



DISEASES OF THE CONJUNCTIVA 153 

Pinguecula and Pterygium. — By pinguecula is de- 
noted a small yellowish elevation which forms on the eye- 
ball in the free space between the lids and the inner margin 
of the cornea and the caruncle, a small fleshy structure in 
the inner corner of the eye. Ordinarily pinguecula is of no 
significance, beyond the slight cosmetic blemish it entails. 
At times, however, in persons exposed to the weather and 
to the irritation of smoke, heat, etc., this little elevation may 
attain considerable growth, expanding in fan-like fashion 
to the margin of the cornea externally and to the fold of 




^IS 



Fig. 60. — Pterygium. 

mucous membrane observable at the inner angle of the eye 
internally. When it has reached this development, the 
term pterygium (Fig. 60) is assigned to it. Although at- 
tached to the cornea and overlapping it, pterygium rarely 
occasions more than slight visual disturbance by the astig- 
matism which it evokes. Pseudo pterygium may, however, 
develop in consequence of injuries and burns of the cornea, 
and, when extensive, seriously jeopardize vision by involv- 
ing that part of the cornea directly over the pupil. Ptery- 
gium is amenable to operation, and may be removed by 
excision or transplantation. 



CHAPTER X 

DISEASES OF THE EYELIDS, LACHRYMAL AP- 
PARATUS, CORNEA, IRIS AND VITREOUS 

The outer surface of the eyelids may participate in 
most of the diseases of the skin affecting the face, such as 
eczema and erysipelas. The lids may also be the seat of 
various benign and malignant tumors. Among the former 
may be mentioned nasvi, or blood tumors, of different 
sizes, and warts. Among the latter, epithelioma, or skin 
cancer, is the most common. Removal of the benign 
growths is usually recommended for cosmetic purposes, 
but as it frequently happens that malignant growths ap- 
pear at the site of warts and pimples which have been 
irritated, the early extirpation of all such formations should 
be advised, with a view to the avoidance of future trouble. 

Though the skin cancers affecting the lids grow slowly, 
their progress is constant, the deeper structures of the lids 
and sublying tissues being also involved, so that in time 
the entire structure of the lid is eaten away by the cancer, 
robbing the eyeball of its protection. 

In the early stages, various forms of electricity and 
radium are very efficacious, but when extensive changes 
have occurred, excision with the knife, conjoined with the 
superposition of skin grafts or flaps of skin transposed 
from the surrounding tissues, is necessitated. 

Inflammation of the margin of the lids, or blepharitis 
marginitis, as it is termed, is a common affection, occurring 
in both children and adults who are in poor health or who 
are suffering from uncorrected errors of refraction. The 

154 



DISEASES OF THE EYELIDS 155 

condition is essentially chronic and is attended by the for- 
mation of crusts and ulcers on the margin of the lids. The 
hair follicles become involved, and many of the eyelashes 
are lost, often permanently. 

In consequence of the participation of the hair follicles 
in the process, suppuration of the cavity from which the 
lashes grow may occur, and a stye or hordeolum appears. 
These painful swellings may occasion a very marked cedema 
of the tissues of the lid, and may give rise to considerable 
disturbance of the general system before pointing and 
spontaneous evacuation of their pussy contents. As pus- 
producing microorganisms are always present, other glands 
become infected and successive crops appear. 

The cure of styes is often therefore difficult. The re- 
moval of all predisposing causes must first be essayed. 
Any tendency to constipation must be overcome by suitable 
laxatives, digestive disturbances corrected, and tonics ad- 
ministered. In obstinate cases, the hypodermic adminis- 
tration of vaccines is often of value. Locally, the inflam- 
mation of the lid margin, often primarily responsible for 
the development of styes, should be allayed, by thorough 
removal of all crusts with an alkaline wash and the appli- 
cation of silver nitrate or of a salve composed of varying 
strengths of the yellow oxide of mercury. The proprietary 
salves advertised for the cure of styes generally contain 
this ingredient. 

Styes may often be aborted by applying strong solu- 
tions of sulphate of zinc to the aif ected region, or by touch- 
ing the infected hair follicle with carbolic acid. As contact 
of either of these substances with the exterior of the eye 
would be injurious, such applications should be made only 
by competent medical practitioners. If abortive measures 



156 



HYGIENE OF THE EYE 



fail, incision with a sharp knife should be made the moment 
pus forms. 

The common practice of poulticing the eye with flax- 
seed, tea leaves, etc., while giving relief to pain, on account 
of the heat and moisture they afford, is injurious, on 
account of the spread of the microorganisms which these 
factors favor. Should poultices be applied, only those of 
antiseptic properties, such as bichloride of mercury or witch 
hazel, should be employed. 

Chalazion (Fig. 61). — Another common and often 




Fig. 61. — Chalazion. (Posey & Wright; Lea & Febiger.) 

painful affection of the lids results from an enlargement 
of one or more of the glands which aid in the lubrication 
of the hair follicles. According to the number of glands 
implicated, small swellings or chalazia form under the skin, 
which disfigure the contour of the lid, and, often attaining 
considerable size, press on the eyeball and interfere some- 
what with vision. These growths may remain quiescent 
for months and occasion no symptoms other than those just 
referred to; in other cases, however, the contents of the 
glands suppurate, giving rise to pain and considerable irri- 



DISEASES OF THE EYELIDS 157 

tation of the conjunctiva. The relief of this condition 
consists in early incision and evacuation of the contents of 
the swelling with a small spoon-shaped instrument. 

Displacement of the Eyelashes and Irregulari- 
ties IN the Form and Position of the Eyelids. — Fre- 
quently after burns and other injuries and long standing 
disease of the conjunctiva and lids, the symmetry of the 
row of lashes is interfered with, and the margins of the 
lids no longer maintain their nice coaptation to the globe, 
but roll either in or out. These conditions are present in 
nearly all cases of trachoma, and the irritation of the eye- 
ball by the misplaced lashes, the so-called " wild hairs," is 
often one of the most distressing features of the disease. 
Operative measures are usually necessary to correct the 
evil and a large number of procedures have been devised to 
restore the normal contour of the lids and to remove the 
row^ of lashes from contact with the globe. 

Ptosis. — Another disfiguring lid anomaly is produced 
by a failure in innervation of the muscles which raise the 
upper lids, in consequence of which the lids droop and par- 
tially cover the eyeballs, imparting a drowsy appearance 
to the patient, and necessitating the throwing back of the 
head to obtain clear vision through the partially covered 
pupils. This condition of ptosis (Fig. 62) , as it is termed, 
may occur at any time of life, from paralysis of the nerves 
supplying the elevators of the lids, or may be present at 
birth. 

^ledicinal treatment may remedy the deformity due to 
paralysis, but some form of operation which unites the lids 
to the nervous supply of the muscles which raise the brow 
is necessary for the correction of the congenital variety. 
Congenital ptosis is often associated with an obliquity of 



158 HYGIENE OF THE EYE 

the palpebral fissures and an abnormally broad fold of 
skin at the base of the nose, imparting a Mongolian type 
of features to those suffering from this rather uncommon 
anomaly. 

A painful, though fortunately a not very common, affec- 
tion of the lids consists in the eruption of a number of 
small blisters over one of the nerves supplying the skin. 
This affection, designated as herpes zoster, is in associa- 
tion with the outbreak of similar vesicles on the skin ad- 
joining the lids, and often on the eyeball. A sharp line of 
demarcation separates the inflamed area from the unin- 



FiG. 62. — Congenital ptosis. 

volved side of the face. In the event of ocular complica- 
tions, serious impairment of vision may follow. 

Diseases of the Orbit. — Injuries to the orbit may 
cause fracture of its bony walls, and by implication of the 
optic nerve as it passes through the bony aperture in the 
apex of the orbit, may lead to sudden and complete blind- 
ness. The orbit may be the seat of tumors which cause 
displacement of the globe and interfere with vision. 

On account of the proximity of the large air spaces, or 
sinuses, which communicate with the nose, the cavity of the 
orbit not infrequent^ participates in inflammatory condi- 



DISEASES OF THE EYELIDS 159 

tions of those structures. Pus in a sinus may give rise to 
abscesses in the orbit, and the inflammatory process attack- 
ing the eye may lead to serious disease of that organ. 

Diseases of the Lachrymal Apparatus. — Diseases 
of the lachrymal gland are rare. Derangements of the ex- 
cretory portion of the apparatus, however, of the canaliculi, 
the small apertures situated upon the nasal extremities of 
both lids, of the sac and of the duct, are very common. In 
consequence of such disorders, the tears cannot pass from 
the conjunctival sac into the nose, but flow instead over 
the lid upon the cheek. This annoying condition may also 
be occasioned by anything which interferes with the nice 
coaptation of the lids to the globe, a requisite in the proper 
conveyance of the tears into the sac. 

Injuries of the lids and inflammatory changes in their 
structures are examples of some of the conditions which 
alter their position. Annoying lachrymation seems to ac- 
company advancing years, especially in men, upon expos- 
ure to wind and cold, due doubtless to an atony of the 
muscle fibres which surround the sac and aid in the ex- 
pulsion of its contents. The most common underlying con- 
dition, however, is nasal disease, the inflammation mounting 
from the mucous membrane lining the nasal cavity to that 
of the duct. Repeated swelling leads to a gradual occlu- 
sion of the duct and a damming back of the tears and 
mucus in the sac. After a time, the sac becomes distended 
and a perceptible tumor forms just below the inner angle 
of the eye. If this be pressed by the finger, a quantity 
of mucilaginous-like matter wells up into the eye, and in 
cases of long standing, in which inflammatory changes 
have arisen in the mucous membrane of the sac, a thick 
creamy pus may often be expressed. 



160 HYGIENE OF THE EYE 

At times the sac becomes the seat of an intense inflam- 
matory reaction (Fig. 63), giving rise to great pain and 
occasioning marked swelling and redness of the lids and the 
adjacent skin. Unless there be surgical intervention, an 
abscess forms, which usually ruptures through the skin 
over the sac and occasions a permanent fistula. 

Lachrymation is not always dependent upon improper 
drainage, but may be of reflex origin, being an accompani- 
ment of almost all diseases of the eye and frequently ex- 




FiG. 63. — Abscess of lachrymal sac, and mucocele. 

cited by eye-strain. The physician in his endeavor to 
relieve excessive tearing always excludes such reflex causes, 
before directing treatment to the various structures of the 
lachrymal apparatus. 

Diseases of the lachrymal apparatus may be congenital 
and the persistence of a catarrhal condition of the conjunc- 
tiva of one eye should awaken the suspicion of faulty 
lachrymal drainage. 

Formerly, the introduction of probes through the 
canaliculus, into the nose, to overcome any stricture in the 



DISEASES OF THE EYELIDS 161 

sac or duct was largely practised, but in recent years this 
painful and often unsatisfactory process has been sup- 
planted by syringing the inflamed lachrymal passages with 
astringent washes, and when this fails to obtain permanent 
drainage, by the insertion of a piece of lead wire from the 
eye into the nose. Such " stjdes," as they are called, may 
be worn for years, without occasioning disfigurement or 
discomfort to the patient. 

In purulent cases, the excision of the sac is desirable, 
an operation of some difficulty, but without danger to the 
eye or subsequent disfigurement, the resultant scarring 
being usually imperceptible. 

Diseases or the Cornea. — As has been stated in de- 
scribing the anatomy of the cornea, this structure may be 
regarded as the window or watch crystal of the eye, its 
transparency permitting the ready passage of rays of light 
into the interior of that organ. Should, for any reason, its 
transparency be interfered with, the passage of the rays is 
hindered and vision interfered with in proportion to the ex- 
tent and position of the opacity. If the opacity is periph- 
eral and the pupillary area of the cornea escape, vision may 
be normal. The slightest haze, however, of the central 
zone is always attended with more or less impairment of 
sight. 

As the clearness of the cornea would be impaired were 
it provided with blood-vessels, none are present, the nour- 
ishment of the membrane being derived from neighboring 
structures. Owing to this fact the cornea frequently suf- 
fers, in consequence of disease of adjacent organs, also from 
any devitalizing process in the body which diminishes the 
circulatory force and nourishing power. 

The cornea, furthermore, occupies a very exposed posi- 
11 



162 HYGIENE OF THE EYE 

tion and is frequently injured by foreign bodies and other 
forms of traumatism. 

It may be judged from the foregoing that disease of 
the cornea, or keratitis as it is designated, is common, and, 
as a matter of fact, this tiny membrane may exhibit an 
astounding number of pathological conditions, which tax 
the experience of even the most trained observer to prop- 
erly appreciate and catalogue. 

Consideration need only be given here of several of the 
more common affections, with which it seems desirable that 
the laity should be familiar. 

Phlyctenular Keratitis or Eczema of the Cornea. — This 
disease occurs for the most part in scrofulous children, but 
occasionally in debilitated adults. Children so aiFected 
present other signs of scrofula, i.e., a discharging nose, 
swollen lips, enlarged lymphatic glands and diseases of 
bones and joints. An eczematous condition of the face 
and scalp is also frequently present. Many subjects are 
distinctly tuberculous. The disease often follows the erup- 
tive fevers of children, and occurs usually in warm and 
moist weather. 

The characteristic lesion, the phlyctenule, a collection of 
cells around a terminal nerve filament of the cornea, dis- 
integrates and forms a small ulcer. Such ulcers may heal, 
leaving but a slight scar, or, under less favorable condi- 
tions, spread both laterally and more deeply into the sub- 
stance of the cornea, destroying its transparency, and in 
some cases lead to its perforation, with subsequent escape 
of the lens and humors within the eye. The enlarged 
white staring eyes, so frequently observed in those blind 
from ophthalmia neonatorum and from other destructive 
types of conjunctivitis, may also be a sequela of corneal 



DISEASES OF THE EYELIDS 



163 



ulceration with perforation, and demonstrate how destruc- 
tive to sight and appearance the involvement of this mem- 
brane in an ulcerative process may become. 

In consequence of the irritation of the exposed ner\^e 
fibrils, the eyes in phlyctenular disease are extremely sen- 
sitive to light, thereby occasioning the greatest distress 
(Fig. 64) . The oculist witnesses no more distressing pic- 
ture than a child with phlyctenular disease, its head buried 
in its mother's bosom to exclude the light, with tears stream- 




FiG. 64. — Little girl leaning over chair, with head buried in cushion — suffering from corneal 

ulcers. 

ing from the eyes, and with the added discomfort of the 
eczematous and scrofulous complication just referred to. 
It is obvious that the first appearance of corneal haze 
demands most careful and rigorous local treatment and 
the best of hygienic and dietetic care to build up the health 
of the child to nourish the impoverished cornea. It needs 
but a few days of inactivity as regards treatment to hope- 
lessly destroy or at least seriously impair vision in such 
cases for life. The folly of resorting to such household 



164 HYGIENE OF THE EYE 

remedies as bandaging the eyes with tea leaves, in piercing 
the ears, as is the custom in some of the southern countries 
of Europe, in the hope of drawing off the inflammation to 
another organ, or in securing anything short of the best 
ophthalmic advice possible, must be evident. In cities, hos- 
pitals and dispensaries abound where the poor ma}^ receive 
especial care and treatment, and in the country the aver- 
age medical practitioner is usually able to cope with such 
cases. The social service worker is of the greatest service 
in aiding in the treatment of this class of cases, accompany- 
ing the patients to their homes and demonstrating to the 
household all that is comprised by the term general hygiene. 
Owing to the protracted nature of many forms of ulcer of 
the cornea, in cities, especially where it is difficult for the 
medical advisers to maintain a proper oversight over am- 
bulatory cases, the social worker not only sees that treat- 
ment is carried out, but assures the reporting of the patient 
for clinical oversight and direction at the desired intervals. 

Interstitial Keratitis. — The preceding description 
dealt with an ulcerative inflammation of the cornea which 
afl*ected primarily the superficial layers. Interstitial 
keratitis, on the other hand, affects the deeper layers, and 
in most cases is unaccompanied by ulceration, the inflam- 
mation being attended with deposits of lymph in the cornea, 
which do not ordinarily destroy the corneal tissue. Though 
at times the infiltration of lymph may convert the cornea 
into a perfectly opaque membrane, this opacit}^ is capable 
of absorption, and after a variable period the cornea may 
clear and vision be restored to normal. 

In neglected cases, however, the outcome of interstitial 
keratitis is fully as serious as that of inflammation of the 
more superficial layers of the cornea, the disease having a 



DISEASES OF THE EYELIDS 



165 



marked tendency to spread backward into the interior of 
the eye and involve the iris, cihary body and choroid. In 
consequence of these comphcations, certain irremedial con- 
ditions arise, which cause bhndness. 

The most common causes of this type of keratitis are 
syphihs and tuberculosis. Although at times excited by 
acquired sj^philis, congenital syphilis, that variety which 




Fig. Go. — Hutchinson's teeth. 



is communicated to the offspring by tainted parents, is 
usually responsible, the disease appearing generalh^ at 
adolescence, though cases have been observed as early as; 
six years and as late as thirty years of age. In rare cases 
the disease may originate while the child is still in em- 
bryonic form and incurable blindness be present at birth. 

Syphilitic subjects of interstitial keratitis usually ex- 
hibit other signs of congenital syphilis, the nose being 



166 HYGIENE OF THE EYE 

sunken, the skin pale, the knee-joints inflamed, and the 
face scarred with deep hnes radiating from the angles of 
the eyes, nose, and mouth. A peculiar notching or chisel- 
shape of the upper permanent incisor teeth is particularly 
characteristic (Fig. 65), Inquiry will frequently elicit 
that several " still born " births have preceded the birth 
of the patient, or that several babies born previously have 
died in early infancy. The experienced diagnostician can 
frequently establish a diagnosis in such cases from the his- 
tory alone without even a glance at the eyes. 

Both eyes are usually affected. The first manifesta- 
tions are a diffuse zone of redness about the cornea, a lack 
of lustre in this membrane, some dread of light, and ex- 
cessive lachrymation. After a time, small islets of opacity 
form in the deeper layers of the cornea. These soon coal- 
esce, increasing the haze of the membrane and preventing 
access of the rays of light into the interior of the eyes. In 
an effort to clear the cornea, blood-vessels from the sur- 
rounding structures form at the corneal margin. 

The symptoms persist for weeks and months, but if 
promptly and energetically treated, the eyes may recover, 
with practically normal vision. 

Even in the event of recovery, the long suffering en- 
tailed by interstitial keratitis and the weakness of the eyes 
which persists for years afterwards make it a most formid- 
able disease, and offer strong argument against the mar- 
riage of those tainted with syphilis. Modern science has 
evolved tests by means of which the existence of syphilis 
in individuals may be definitely proven. In view of the 
tragedies which may follow, it does not seem too much to 
insist upon the submission of suspected contracting parties 



DISEASES OF THE EYELIDS 167 

to such tests before parental and legal acquiescence to mar- 
riage is granted. 

Diseases of the Iris. — Diseases of the iris are second 
to no others in their importance, either in the frequency of 
their occurrence or in respect to the irreparable damage 
which may arise from neglect or maltreatment of them. 
In addition to inflammatory affections, the iris may be the 
seat of congenital malformations, the most important of 
these being so-called colobomata. These are gaps of vari- 
able size, which may extend from the pupillary margin to 
the periphery and in some cases may be continuous with 
similar fissures in the ciliary body or choroid. In several 
interesting cases of this nature reported by the author, the 
pupil, in consequence of anomalous formations in the iris, 
was elongated and slit-like, resembling that of the cat. 
Such anomalies are often hereditary and may be observed 
in successive generations. 

The danger of iritis to the integrity of the eye lies in the 
tendency the membrane has to adhere to the sublying lens, 
in consequence of a tenacious exudate which is poured out 
from the iris in an inflamed state. Such adhesions not 
only influence the development of cataract by interfering 
with the nutrition of the lens fibres, but also block the chief 
avenue of escape of the intra-ocular fluid, as it flows from 
the posterior to the anterior part of the eye, thereby 
damming up the fluids within the eye and giving rise to 
glaucoma. At times the exudate blocks the pupil and 
hinders the passage of the rays of light into the eye. 

Iritis is generally a disease of adult life and occurs much 
more frequently in men than in women. In addition to the 
visual disturbances with which it is attended, marked in- 
flammatory symptoms are also present. The pupil becomes 



168 HYGIENE OF THE EYE 

contracted and the blood-vessels suiu'ounding the cornea are 
much congested, though those of the conjunctiva also take 
part in the congestion. Pain is a constant symptom, usually 
most aggravated as night approaches. There is no dis- 
charge from the conjunctiva, though increased lachryma- 
tion is easily excited by exposure to light or any other form 
of irritation. The interstitial portion of the cornea usually 
participates in the inflammation, and produces a diffuse 
haze of that membrane. The ciliary body also rarely 
escapes and the neighboring portions of the choroid show 
implication. 

The causes of iritis are varied. Some form of con- 
stitutional disease or inflammatory focus elsewhere in the 
body is generally responsible. 

Acquired syphilis probably occasions more than half 
of the cases. The so-called secondary stage of the disease 
is particularly apt to be complicated by iritis, about the 
same time as the characteristic rash breaks out upon the 
skin; more rarely iritis appears in the tertiary period, in 
which event solid rounded masses or nodules, the so-called 
gumma of syphilis, appear either in single or multiple form 
upon the iris. 

Articular rheumatism is also accompanied by iritis, this 
being especially the case when a gonorrhoeal element is 
present. The causal connection between gonorrhoea and 
iritis is often overlooked in consequence of the long lapse 
of time which frequently occurs between the appearance 
of the ocular manifestation and the primary attack of 
gonorrhoea. The gonorrhoeal virus may, however, remain 
dormant somewhere in the genito-urinary system for years, 
and though incapable of exciting local irritation in the 
genitalia may be absorbed by certain membranes of the 



DISEASES OF THE EYELIDS 169 

body, such as the joints and iris. Iritis may, however, occur 
in rheumatic subjects in whom no trace of gonorrhoea is 
present, and some of the most intractable cases the author 
has ever treated have occurred in old ladies suffering from 
that disabling and deforming type of rheumatism known 
as rheumatoid arthritis. 

Tuberculosis may also play a causal role, and this is 
particularly true in the negro, a race peculiarly suscepti- 
ble to tubercular infection. Tubercular nodules of the 
iris are readily distinguishable from the reddish-yellow 
gumma of syphilis, by their characteristic grayish-white 
appearance. 

Formerly many cases of iritis were imputed to expos- 
ure to cold and other extraneous causes. Recent investiga- 
tion has shown that with the exception of those due to 
accident, which will be described later, such agencies have 
but little, if no, influence in precipitating an attack, while 
inflammatory foci elsewhere in the body, such as decayed 
teeth, diseased tonsils, inflammation of the surrounding 
sinuses of the nose, etc., are responsible in many instances. 

To the trained observer, the diagnosis of iritis usually 
presents but few difficulties. Much mischief often arises, 
however, in consequence of general practitioners and others 
mistaking the condition for an attack of conjunctivitis, and 
withholding the proper treatment so long that the adhesions 
referred to above have had time to become fixed and un- 
yielding. The prompt and complete dilatation of the 
pupil with atropine or some other drug which acts similarly 
is essential, in conjunction with the treatment of the sub- 
lying constitutional or local source of infection or irritation. 

The proper management of iritis should always be rele- 
gated to an ophthalmologist, when this is possible, for there 



170 HYGIENE OF THE EYE 

is some danger in those not thoroughly trained in the science 
of ophthalmology supervising the instillation of atropine 
into the eye. Inflammatory glaucoma often presents a 
picture not very dissimilar from iritis, and cases have oc- 
curred where the practitioner, judging the attack to be 
iritis, and instilling atropine for its relief, has precipitated 
blindness by employing a drug which dilated rather than 
contracted the pupil. Fortunately, the severity of the 
symptoms following usually leads to the recognition of the 
error, and prompt operative interference saves the sight, 
but the damage to vision likely to arise from such mistakes 
is too great not to warrant every precaution being taken 
to avoid them. 

Diseases of the Vitreous. — Aff*ections of this humor 
are always secondary to those of structures surrounding it, 
and frequently give rise to impairment of vision, by the cre- 
ation of opacities which vary greatly in size and number. 
The most common symptom attending vitreous disease is the 
appearance of motes or muscse before the eyes, which are 
treated at length elsewhere (page 182) . Near-sightedness 
of high degree is usually attended with considerable altera- 
tion in the structure of the vitreous and becomes a factor 
in the detachment of the retina which sometimes occurs 
in this form of eyeball. Injuries of the eye which per- 
forate into the vitreous not infrequently cause the loss 
of the eye from suppuration, as its structure afl*ords a 
fertile soil for the growth of virulent forms of micrococci. 



CHAPTER XI 

DISEASES OF THE INTERIOR OF THE EYE; 
CHOROIDITIS, RETINITIS, OPTIC NEU- 
RITIS AND OPTIC ATROPHY 

The diseases of the ocular structures which have just 
been described are all more or less evident to external exam- 
ination. It is true, as has been stated, that a diagnosis of 
cataract or glaucoma cannot be substantiated without ex- 
amining the interior of the eye, but even these two condi- 
tions give some external evidence of their existence. Dis- 
eases of the interior of the eye, however, demand an oph- 
thalmoscopic examination for their detection, and the pos- 
sibility afforded by this wonderful instrument of exploring 
the fundus and studying the changes observed there, is one 
of the greatest achievements of science. 

Diseases of the Choroid 

Like the iris, the choroid may also be the seat of con- 
genital anomalies. The cleft or coloboma described in the 
iris may be continued back into the choroid, or a similar 
fissure may occur in the choroid alone without participation 
of the former membrane. This anomaly is explained by 
some obstacle to the proper closure of the cleft in the eye 
which is present during intra-uterine life. 

A more common condition is albinism, or congenital 
lack of pigment in the choroid and iris. In consequence 
of this absence of pigment, the iris presents a pinkish ap- 
pearance, due to the reflection of light from the blood-vessels 
within the interior of the eye. Albinism is associated with 

171 



172 HYGIENE OF THE EYE 

lack of pigment in the hair. Vision is usually much dis- 
turbed, both on account of lack of protection from the ab- 
sence of pigment, and by the presence of high refraction 
errors. The condition is incurable. Several members of 
a family are often affected and there is a marked heredi- 
tary tendency towards the transmission of the condition. 

As stated in a previous chapter, the choroid is the vas- 
cular coat of the eye and in close association with the retina. 
Inflammations of this membrane, which are invariably at- 
tended with exudation, almost always cause involvement 
of the latter, with resultant visual disturbances. Reduc- 
tion in vision may also result from the haze of the lens 
and vitreous which may be occasioned by choroiditis. 

There are no symptoms of which the patient is con- 
scious which may be said to be characteristic of choroiditis, 
the diagnosis being made by means of the ophthalmoscope. 

The changes observed in the interior of the eye in con- 
sequence of choroiditis are, briefly, the presence of exuda- 
tions, disturbance in the choroidal and retinal pigment with 
absorption in the later stages, and vitreous haze, if this 
humor be affected (see Plate II, D) . 

Like diseases of other structures of the eye, choroiditis 
assumes a multiplicity of forms, a description of which is 
outside the scope of the present work. Disease of the 
choroid accompanying myopia has already been referred to. 

The chief causes of choroiditis are syphilis, tuberculosis, 
other infectious processes in the economy, and an extension 
of inflammatory processes from other ocular structures. 
Tuberculosis may involve the choroid, either in the form 
of single or multiple growths. When multiple, they are 
usually associated with similar deposits in the membranes 
of the brain and form part of the general symptomatology 



DISEASES OF THE INTERIOR OF THE EYE 173 

of tubercular meningitis. Unfortunately, however, their 
late appearance in the eye, usually but a few hours be- 
fore death, detracts from their value in substantiating the 
diagnosis of this, at times, obscure disease of the brain. 

At times choroiditis may assume a suppurative char- 
acter from infection from extraneous causes, or in rarer 
cases by the transference of purulent emboli or clots from 
some suppurating focus within the body. The former mode 
of infection sometimes happens after injury of the eye, the 
latter in puerperal fever following childbirth. Loss of 




Fig. 66. — Sarcoma of the choroid. (After Leber.) The tumor, G, rises from the choroid 
C, which everywhere lies in contact with the sclera. The retina, A'^, on the contrary, is detached 
entirely from its bed under the form of a folded funnel. It retains its connection only ^ath the 
papilla behind, and with the choroid along the ora serrata, O, in front. (Fuch's Ophthalmology.) 

sight and subsequent shrinking of the eye always follow. 
The choroid is the most frequent seat of malignant 
tumors within the eye ( Fig. 66 ) . These may not only 
destroy the eye, but may also cause death by metastasis or 
spread to other organs. The most common form of 
choroidal tumor is the so-called pigmented sarcoma, a 
variety of cancer which affects the eyes of adults. The 
growth of this tumor is ordinarily slow and vision may be 
but little affected for a number of years. It is desirable, 
however, that such tumors be detected as soon as possible 
and the eye containing them removed, for early operation 



174 HYGIENE OF THE EYE 

is the only means of preventing the spread of the cancer 
and of saving the patient's life. In some cases, instead of 
spreading to distant organs, the tumor breaks through the 
eye and invades the orbit, necessitating the removal of the 
eye with all the surrounding orbital structures. A local 
recurrence of the growth in the orbit sometimes occurs 
after the removal of the eye with the tumor enclosed and 
without there being any evident invasion of the orbit. 

Retinitis. — Diseases of the retina may assume a 
variety of types, dependent upon their cause. All, how- 
ever, have certain ophthalmoscopic manifestations in com- 
mon, namely, haze and swelling of this membrane, exuda- 
tions, and hemorrhages from the retina vessels, and more 
or less implication of the optic nerve. The products of 
inflammatory change within the retina may vary from an 
almost imperceptibly small hemorrhage to a mass of blood 
extravasation, and from a minute area of lymph efl^usion 
to a saturation and infiltration of the retinal structure 
which entirely changes its appearance. As retinitis is usu- 
ally occasioned by some disease of the general system, such 
as syphilis, tuberculosis or disease of the kidneys and blood- 
making apparatus, the recognition of the various types of 
inflammation is of great value to the clinician, and, as has 
been said elsewhere, frequently leads to the early recogni- 
tion of diseases whose existence has been unsuspected both 
by clinician and patient. For a description of retinitis of 
Bright's disease, and diabetes and of the blood-making ap- 
paratus, see pp. 210 and 211. Of no less value are the 
changes which occur in the retinal vessels, which have been 
described in another chapter. 

In consequence of advanced vascular disease, the main 
artery of the retina may become obstructed by a clot and 



DISEASES OF THE INTERIOR OF THE EYE 175 

sudden blindness ensue. Frequently such attacks of blind- 
ness are but transient, vision being regained after a few 
minutes. After a number of such attacks, blindness usu- 
ally becomes permanent, indicating that the clot has filled 
the lumen of the vessels and no more blood can enter the 
eye. Sudden total blindness in one eye, without prelimi- 
nary attacks of loss of sight, may at times be occasioned 
by the lodgement of a clot or embolus, which has been 
whisked off a diseased valve of the heart, into the central 
artery of the retina. As a rule, but one eye is affected. 

Mild forms of retinitis may be set up by uncorrected 
errors of refraction and by exposure to intense light. 

Retinitis may also occur in both congenital and acquired 
syphilis, in the latter, as a rule, about a year after the in- 
fection has been received. 

Of particular interest to laymen, on account of its 
sociological features, is a rather rare form of retinitis known 
as pigmentary degeneration of the retina. This disease 
of the retina is associated with a wasting or atrophy of 
the optic nerve and is characterized by the deposit of 
peculiarly shaped pigment masses in the substance of the 
retina, and by hemeralopia or night blindness. This lat- 
ter symptom, almost characteristic of the disease, evidences 
itself in a marked reduction of the visual acuity as soon as 
twilight appears, subjects of the affection who have had 
but little difficulty finding their way about in daylight 
being suddenly deprived of this power. In the terminal 
stages of the disease, vision becomes much affected, and 
useful vision is usually lost. This form of retinitis occurs 
in deaf mutes and idiots, but in others also who have no 
form of disease of the nervous system. The disease is 
strongly hereditary and consanguinity of the parents of 



176 HYGIENE OF THE EYE 

the patient has been discovered so often that there seems 
to be no doubt as to the influence played by the intermar- 
riage of relations. 

In a statistical study made by the author some years 
ago to determine the frequency of the relationship of con- 
sanguinity to blindness in the United States, it was found 
that the parents were related as cousins in 4.5 per cent, of 
the cases recorded. Analysis of a large number of cases 
of this form of retinitis has shown that consanguinity can 
be traced in about 25 per cent, of the cases. These figures 
seem sufficient proof of the liability of consanguineous mar- 
riages to originate serious ocular disease and demonstrate 
the desirability for the prohibition of such unions by law 
and of their discouragement by society. 

Retinal Detachment. — The retina under certain 
conditions may become detached from the choroid and 
encroach upon the vitreous, in consequence of effusion of 
blood or lymph beneath its surface. 

Upon ophthalmoscopic examination, the retina appears 
as a floating grayish-white membrane with the retinal ves- 
sels running over it. Naturally vision is much restricted, 
the part of the visual field corresponding to the area of the 
detachment being lost. This accident occurs chiefly after 
blows upon the eye and head, near-sighted eyes being espe- 
cially liable, in consequence of disease of the vitreous. 
Certain diseases of the choroid and retina which are at- 
tended with copious hemorrhage or lymph extravasations 
may also give rise to the condition. The retina rarely 
escapes detachment when tumors invade the interior of the 
globe. 

Treatment is usually unsatisfactory, though some cures 
may be wrought if early treatment is inaugurated. Drain- 



DISEASES OF THE INTERIOR OF THE EYE 177 

ing off the fluid from beneath the retina by means of an 
incision into the sclera, and absorbing the fluid by sweat 
baths and internal medication, while the patient lies flat 
upon the back for a period long enough to insure the ad- 
hesion of the retina to the sublying choroid, offer the best 
chances for reestablishment of vision. 

Tumors of the Retina. — The most common form of 
tumor of the retina is a variety of cancer, glioma, so called, 
which occurs not very rarely and for the most part in 
young children. In the early stages there are no external 
evidences of the disease, the existence of the growth being 
usually first detected by the mother upon the appearance 
of a whitish mass in the pupil. 

If the eye with the contained tumor is at once removed, 
there is some chance that the disease has been eradicated. 
Unfortunately, however, such cases rarely come to opera- 
tion until the optic nei^ve has been implicated, so that, after 
varying intervals of time, there is either a recui'rence of 
the growth in the orbit, or meningeal symptoms develop, 
showing that the tmnor has invaded the brain. The sub- 
sequent course is extremely distressing, the tumor mass 
in the orbit attaining great size and occasioning marked 
deformity. Death follows from the invasion of the brain 
by the cancer. 

Optic Neuritis. — As has been stated in a previous chap- 
ter, the optic nerve is really a portion of the brain, con- 
formed into a nerve-trunk to carry visual impulses from 
the eye to the brain. ]Many diseased conditions within the 
brain are manifest in the nerve, so that the opportunity 
afforded by the ophthalmoscope of actually viewing and 
studying the changes which occur in the head of this struc- 
ture is made use of as a part of routine examinations in 

12 



178 HYGIENE OF THE EYE 

all cases of suspected disease of the central nervous system. 

The optic nerve, being continuous through the medium 
of its fibres with the retina, participates in many inflamma- 
tions of that structure — indeed, it is usually more or less 
involved in nearly all forms of severe inflammation within 
the eye. The optic nerve may also be the seat of primary 
inflammation, and shows a peculiar susceptibility to be 
affected by a variety of diseases of the general system, 
such as syphilis, diabetes, and renal disorders, and by the 
action of certain poisons. It may also be the seat of 
tumors. 

Ordinarily optic neuritis manifests itself ophthalmo- 
scopically by a blurring of the edges of the nerve, in con- 
sequence of a swelling and opacification of the nerve fibres 
as they pass over its edge to spread out over the surround- 
ing retina, and the skilled observer has but little diffi- 
culty in arriving at a diagnosis. At times, however, slight 
degrees of blurring of the nerve edges and nerve fibre 
opacification may be entirely physiological, and a nice judg- 
ment and much experience is demanded to properly judge 
of the true nature of the condition present. 

The most striking changes in the nerve are observable 
in cases of brain tumor (see Plate II, F) . Indeed the oph- 
thalmologist is frequently the first to suspect the existence 
of such a growth, the headaches occasioned by the tumor 
being attributed by the patient to eye-strain, and ophthal- 
mic aid sought in the expectation that glasses might relieve 
this symptom. Ordinarily, despite the extreme swelling 
of the head of the nerve which is discovered at the examina- 
tion, vision is unaffected, the loss of sight which so con- 
stantly attends cerebral growths manifesting itself later. 

Frequently such tumors may implicate some of the 



DISEASES OF THE INTERIOR OF THE EYE 179 

visual centres and tracts within the brain and one or more 
of the nerves which supply the ocular muscles, so that the 
results of the ocular examination are of the greatest im- 
portance in the localization of brain growths, often en- 
abling the neurologist and surgeon in attendance to deter- 
mine with precision the exact site and something of the 
nature of the intracranial growth. 

As the cause of the optic neuritis in such cases has been 
found to be dependent in large measure upon the increased 
tension which such growths occasion within the brain, even 
in cases where localizing symptoms are absent, or in which 
the removal of the tumor from the brain is impracticable, 
it has been found desirable to lessen the cerebral pressure 
by trephining the skull, to avert the blindness which is 
almost inevitable, in consequence of the damage wi^ought 
upon the structure of the nerve. Such procedures are 
known as decompression operations. 



CHAPTER XII 

SOME VISUAL PERCEPTIONS 

These may vary from the perception of " sparks " and 
" motes " to the appearance of figm-es and objects and even 
more comphcated hallucinations. While frequently but 
the exponent of some diseased condition within the eye, 
they are often occasioned by some disturbance transient or 
otherwise of that portion of the brain which controls the 
visual acts. Thus, for example, generally speaking, sparks 
or phospheneSj as they are designated, are induced by 
stimulation or irritation of the retina or of the optic nerve 
and its proliferations into the brain; motes, or muscce^ as 
they are called, are occasioned by the perception of imper- 
fections within the eye. 

Although the mechanism of the eye is extremely deli- 
cate and accurate, its media are far from being uniformly 
transparent, and it possesses many imperfections, which 
prevent the functions of the component parts from always 
being performed with absolute perfection. In addition 
to a blind spot which is projected in the visual field, some- 
what externally to the point of fixation at which the eye 
may be directed, there are numerous imperfectly trans- 
parent parts in all parts of the refracting media. The 
rays of light in passing through these undergo local ab- 
sorption and refraction and cast shadows upon the retina. 
These motes may become evident when one looks directly 
toward the sky or regards some resplendent and highly 
illuminated object, as a field of snow, a sheet of white 
paper^ or the field of a microscope. 

180 



SOME VISUAL PERCEPTIONS 181 

Were it not for the fact that the great majority of 
people are unconscious of these imperfections which the eye 
naturally exhibits as an optical instrument, its efficiency as 
an organ of vision would be seriously interfered with. 
Happily, however, they are totally ignored in the vast 
number of instances, by the habitual inattention which is 
paid to any indirect visual impression. 

The attention of some, whose eyes are particularly 
sensitive or have become greatly weakened by over-fatigue 
and other causes, is at times engaged by these bodies, how- 
ever, and their perception often excites the greatest anxiety 
and discomfort. Such individuals become the ready prey 
of charlatans, who add to their fears by the assurance that 
such motes will lead to speedy blindness unless relieved 
by their nostrums. These poor dupes are then subjected to 
years of the severest treatment, only to have their muscse 
still undiminished and their minds still burdened with 
anxiety and fear of approaching blindness. 

The presence of these natural or physiological motes 
is a symptom of no great importance, for they are ob- 
served in persons whose eyes are perfectly healthy, but 
there are other muscce which are the eocpression of some 
diseased state. This second variety is occasioned by an 
opacity of some of the parts of the eye which are usually 
transparent. The faintest haze of the cornea will throw 
a shadow, and the slightest impediment to the passage of 
the rays will distort the retinal pictures. A young lady 
under the author's care with a diffuse haze of the cornea 
sees twenty distinct moons whenever she regards that body. 
In referring to the disturbance of objects occasioned by 
the formation of a beginning cataract, an ancient authority 
cites the case of the lamplighter of a castle, who was so 



18^ HYGIENE OF THE EYE 

startled by the myriad of lights which burst upon his gaze 
after he had lighted the lamps in the banquet hall before a 
feast, that he feared a ghostly visitation. This disturb- 
ance of images is one of the earliest signs of incipient 
cataract, and often leads the patient to consult a physician 
before any appreciable diminution in the vision has 
occurred. 

The most common form of motes is that caused by the 
presence of floating bodies in the vitreous humor, the so- 
called muscce volitantes. These assume various forms, 
sometimes resembling spots of various shapes and sizes, 
as that of a cobweb. More often there is the likeness of an 
insect, as a spider, worm, or fly. Sometimes they look like 
streaks or lines, and sometimes they resemble sparks and 
stars, strings of bright beads, or filamentous bands. Al- 
though usually kaleidoscopic, changing their form rapidly 
and frequently, at times they remain stationary, and a 
number of people have come under the author's notice who 
have been conscious of muscae for twenty years or more, 
without the slightest change in their number or form. 

When they are numerous they interfere greatly with 
vision and are a source of great annoyance. They move 
with the eye and appear to descend when the eye is turned 
upward and vice versa. These motes are most commonly 
seen in myopic eyes, for in this form of eye, the retina 
being situated more posteriorly, bodies floating in its vitre- 
ous project large diffusion circles upon it; but they are 
also observed in many diseases of the tissues of the eye, and 
while they may often be of a harmless nature, they may 
also be indicative of grave change within the eye, and their 
presence should always be made the occasion for a careful 
examination. 



SOME VISUAL PERCEPTIONS 183 

As has been stated in the opening paragraph of this 
chapter, visual perceptions of various kinds may be excited 
by diseases of the brain. Nearly every form of insanity 
is attended at some time or other by visions of hallucina- 
tions, and these appear in an innumerable variety of forms. 
Epileptic attacks are frequently ushered in by visual sen- 
sations. These may be very slight at times, but a passing 
obscuration, being compared by the patient to the appear- 
ance of air that has been heated over a stove. The patient 




Fig. 67. — Scintillating scotoma in migraine. (Posey & Wright; Courtesy Lea & Febiger.) 

may be annoyed by the presence of a domestic animal, or 
he may see troops of soldiers passing in review before him. 
He may be startled by the appearance of a ghostly figure 
or terrified by the apparition of a bloody spectre. 

These subjective sensations may or may not be colored. 
They are frequently described as resembling globes of fire 
of different colors, which possess rotary movements of 
greater rapidity at the periphery of the globe, but the most 
common appearance is that which is known as the " forti- 
fication spectrum " (Fig. 67). This is the appearance of 



184 HYGIENE OF THE EYE 

rays of light resembling darts of fire which form a broken, 
angular line, of which the edges rapidly vibrate as the spec- 
trum passes across the field. At times, in place of the 
spectrum, there may be sudden loss of sight. This is never 
complete, for it involves but half the field of vision. The 
visual defect may begin at the periphery or at fixation, more 
usual in the former position. 

The one-sided character of the perception is a common 
characteristic of many visual sensations dependent upon 
cerebral causes and is a common attendant of that form of 
headache which is designated as sick headache ^ or migraine. 
A young man under the care of the author, a clerk in a 
sugar refinery, accustomed to add double columns of 
figures, was always made aware of an attack of headache 
of this nature by the disappearance of some of the figures 
from the column. This case is somewhat similar to that of 
a man who was only able to see the letters son upon a sign 
which bore the name of Jacohson, 



CHAPTER XIII 

CATARACT 

By cataract is meant an opacity of the crystalline lens 
or its capsule. 

In ancient times it was supposed that the loss of sight 
which could be relieved by the displacement of the lens 
from behind the pupil was due to an opaque substance 
which, cataract-like, had poured down over the anterior 
surface of the lens. This erroneous view held until the 
early part of the 18th century, when actual dissection dis- 
covered that the obstruction offered to the passage of the 
rays of light into the eye was dependent upon an opacifica- 
tion of the lens itself. Cataract, therefore, is an opacity 
within the eye, and not, as many laymen suppose, a skin 
or membrane which forms upon the eyeball itself. There 
is a popular impression that all opacities or growths which 
appear on the eyeball are cataracts, forms of corneal 
opacities and at times conjunctival growths, such as Pingue- 
cula and pterygia, being mistaken for them. 

Although in its later stages, the opacity of the lens 
robs the pupil of its blackness and brilliancy and imparts to 
it a greyish appearance, in its early development cataract 
is imperceptible to the casual observer. 

Cataracts may occur at any age, but are generally ob- 
served in infancy or old age. Infants may be born blind 
in consequence of them and extreme longevity is nearly 
always associated with more or less haze of the lens. Cata- 
racts are often hereditary and this is particularly true of 
the congenital variety. The transmission, as a rule, is 

18.5 



186 HYGIENE OF THE EYE 

direct, the skipping of a generation being unusual. Cata- 
racts of childhood rarely affect the entire lens and a degree 
of vision is usually present. While generally amenable 
to cure by operation, cataracts associated with various con- 
genital ocular malformations are sometimes inoperable and 
their possessors must be relegated to the ranks of the blind. 

The most common form of cataract is that which occurs 
in men and women alike in the later years of life and is 
designated as senile cataract. In this class of cases, the 
lens begins to lose its clearness usually after the 50th year, 
small more or less isolated opaque areas appearing in vari- 
ous portions of the lens. Fortunately, these opacities are 
often in the periphery of the lens, and present no obstruc- 
tion to the passage of the rays of light as they are re- 
fracted by the central portion of the lens after leaving the 
pupil. At times, however, the opacity of the lens occupies 
the central zone from its very commencement and entails 
serious impairment of vision when the cataract is still in a 
very immature stage. 

As opacities in the lens are rarely discoverable by simple 
inspection, their presence is usually manifested by increas- 
ing difficulty in seeing, and particularly in seeing near ob- 
jects clearly. It is a matter of frequent observation that 
patients may lose much of their keenness of perception for 
distant objects without being cognizant of it, the loss in 
vision being detected in an increasing disability in reading. 
No reading glasses with which they are provided give a 
satisfactory clearness and the persistence in close work oc- 
casions headache, watery eyes and other forms of eye- 
strain. At times symptoms directly referable to the visual 
impairment occasioned by the irregular refraction of the 
rays of light through the partially opaque lens will arise, 



CATARACT 187 

and images are distorted and the perception of ob j ects will 
sometimes be reduplicated. A candle-light, for example, 
may appear double or triple. Exposure to sunlight will 
dazzle an eye with central lenticular haze, such eyes seeing 
best when the pupil is dilated in a diminished illumination. 

The tendency of most cataracts is to become complete, 
that is to say, the opacification gradually spreads through- 
out the structure of the lens until its entire substance has 
lost its transparency. This transition is rapid in some in- 
stances, but in ordinary senile cataracts is extremely slow; 
indeed, in many instances the opacification remains more 
or less stationary after its initial development, and the 
haze being localized in the periphery of the lens, many go 
through life with such opacities, without any perceptible 
limitations in vision and unaware of the existence of such 
a condition. It is for this reason that ophthalmologists 
are very chary of informing patients of the existence of 
slight lenticular changes, every ophthalmologist of experi- 
ence having had numerous examples in his practice where 
an ill-advised information by others of the existence of 
cataracts has caused much needless anxiety over a long 
period of years. The author has in mind a lady approach- 
ing 80 years of age, with almost normal vision in each eye, 
who was told by a foreign oculist nearly 20 years ago that 
she had cataracts. 

Cataract to the lay mind means blindness, sooner 
or later, and this diagnosis once rendered, it is impossible 
to completely allay the suspicion of impending danger by 
any qualifications as to slowness of development, etc. 
While it is usually wise to inform some member of the 
patient's family of the discovery of lenticular changes and 
their possible import, to avoid future misunderstanding 



188 HYGIENE OF THE EYE 

and possible recrimination, in most cases a patient should 
only be told that he has cataract when appreciable diminu- 
tion of vision is present or imminent. 

While the lenses of most people in advanced life are 
more or less hazy, senile cataracts are not a product of old 
age alone, and other factors must be present to excite their 
growth. The influence of heredity has been referred to; 
various constitutional diseases also have their effect. 
Among them, diabetes is especially liable to be compli- 
cated by lenticular changes, and may cause cataracts at a 
comparatively early age. Bright's disease and diseases 
of the vascular system are also responsible in a num- 
ber of instances, the lens suffering in its nutrition in 
consequence of alterations wrought in the tissues of 
the structures nourishing it, by an interference with their 
circulation. 

Workers over furnaces frequently develop cataracts, 
through exposure of the eyes to the light and heat rays 
emanating from the glowing coals. Flashes of electric 
light of great brilliancy from short circuitings have also 
produced total opacification of the lens. As will appear 
later, cataracts frequently result from injury. Lenticular 
opacity accompanies many diseases within the eye and the 
loss of sight which attends many cases of disease of the 
choroid and retina is dependent upon this cause. 

The conviction is steadily growing among eye surgeons 
that prolonged eye-strain is responsible for many cataracts, 
and it is now generally recognized that the decrease in the 
number of cataracts among city dwellers may be accounted 
for by the improved conditions under which this part of 
the community carries on its near work. As a rule, the 
citizens of towns are provided with better means of illu- 



CATARACT 189 

iiiination than their fellows in the country and are able to 
avail themselves of the facilities offered by specialists and 
special hospitals to obtain the proper glasses to correct 
their refraction errors. Improper glasses can do much to 
create changes within the eye which manifest themselves 
as cataracts later. 

The diagnosis of cataract is made by means of the oph- 
thalmoscope. By means of this instrument and by focal 
illumination, the character and nature of the lenticular 
opacity may be carefully studied and noted, for cataracts 
may assimie a gi'eat variety of forms, the recognition of 
which is of great significance to the surgeon in determining 
upon the course of treatment applicable to each case. 

Generally speaking, the treatment of cataract is con- 
sidered under two heads, that of incomplete or immature 
cataract and that of complete or mature cataract. 

When cataract is discovered in its incipient stages, after 
the careful connection of the refraction by means of proper 
glasses, the habits of the patient are inquired into and 
changed if they are found to exert any possible deleterious 
effect upon the eyes. The hours of close use of the eyes 
are restricted and caution enjoined regarding their too- 
prolonged use by artificial light. Frequent interruptions 
of a half-hour to an hour in the near use of the eyes is 
advised. 

The care of the general health is essential and particu- 
lar attention given to the condition of the skin, by daily 
baths and regular exercise in the open air. The patient is 
encouraged to take daily walks, their distance being de- 
pendent upon age and strength. 

Smoked glasses are often of service, to prevent daz- 
zling by sunlight. Simple lotions are prescribed, to lessen 



190 HYGIENE OF THE EYE 

any conjunctival irritation, also internal medication given 
to reduce any congestion of the interior of the eye. 

Notwithstanding the claims of certain classes of irregu- 
lar practitioners who advertise their ability to cure and 
absorb cataracts by certain nostrums and manipulations, 
no form of treatment has yet been devised whereby this 
may be accomplished, the improvement in vision thought 
to be gained by such practices being either imaginary upon 
the part of the patient, or due to an improved condition 
of other parts of the eye, the opacification in the lens still 
remaining the same. 

While cataracts cannot be absorbed and hence cannot 
be said to be cured by treatment other than operative, 
their development may often be retarded, and every eye 
surgeon of experience has many patients under his charge 
who have attained a ripe old age without appreciable im- 
pairment of vision. Frequent changing of glasses is often 
necessary to conform with the alteration in refraction oc- 
casioned by changes within the lens, and all patients with 
cataracts should report for observation once or twice 
yearly. ^ 

In addition to the other forms of medication mentioned 
above, the author is of the opinion that in some cases the 
local use of dionine within the eye has some power to lessen 
further lenticular opacification. 

The cure of cataract consists in the removal of the lens 
by operation. In young subjects while the lens is soft, this 
is accomplished by introducing a special form of knife 
needle into the eye, and by cutting the capsule of the lens, 
permitting the aqueous humor to come in contact with the 
lens substance (Fig. 68) . The effect of this commingling 
of the two humors is finally to absorb the entire lens struc- 



CATARACT 191 

ture, the capsule alone remaining. A second needling 
operation, as it is called, divides this membrane, and the 
passage of the rays of light is no longer impeded. Chil- 
dren with congenital cataracts may be operated on by 
this method \\athin a few months after birth, though it is 
usually desirable to wait until 12 or 18 months of age 
have been attained. 

Cataracts in older subjects are not amenable to this 
form of treatment, on account of the greater hardness of 
the lens, and must be removed from the eye by an open- 




FiG. 68. — Swollen opaque lens after needling. 

ing made into the globe through the cornea and extracted 
by the method indicated in the accompanying illustration 
(Figs. 69 and 70). The first step in the operation con- 
sists in the introduction of a wire frame or speculum to 
separate the lids and expose the eye. The eyeball being 
held firmly by a pair of forceps, the cataract knife is entered 
at the junction of the cornea and sclera, somewhat above 
the horizontal plane of the eye, and by gentle to and fro 
movements is made to cut its way out at the upper ex- 
tremity of the corneal scleral junction. The avenue of 



192 



HYGIENE OF THE EYE 



exit being now prepared, a small piece of the iris is ex- 
cised to facilitate the expulsion of the lens and to prevent 




Fig. 69, — Incision of the cornea for the removal of cataract. 




Fig. 70. — Expulsion of lens through corneal incision. 

prolapse of this membrane into the wound during the act 
of healing. Following an incision into the anterior cap- 
sule of the lens by a small but exceedingly sharp knife, the 



CATARACT 193 

lens is cautious!}^ stroked out of the eye by a small spoon- 
shaped instrument, and after a careful cleansing of the 
wound to facilitate its proper closure and insure prompt 
healing, the speculum is removed, the eyeball flushed out 
with a mild antiseptic lotion and a bandage applied. 

This extraction of the lens is usually performed under 
cocaine ansesthesia, and is practically painless. The opera- 
tion lasts but a few minutes, though the patient is incapaci- 
tated for several weeks, until the healing process is finished. 
In about half of the cases, a secondary operation is neces- 
sary before satisfactory vision is obtained. This consists 
in introducing a knife needle into the eye and clearing the 
pupil of remnants of capsule and lens debris which some- 
times remain after the primary operation. 

If the eye from which the cataract has been removed 
was practically of normal build, that is to say, emmetropic 
before the cataract developed, after the removal of the 
cataractous lens, it is necessary to supply the eye with a 
focussing power equal in strength to the lens which has 
been removed. This is accomplished by prescribing a lens 
to be worn before the eye in spectacles of much the same 
spherical strength as the crystalline lens. With this lens it 
is usually necessary to combine a cylindrical lens of moder- 
ate strength to correct the astigmatism resulting from the 
corneal incision. 

The cataract operation is successful in the majority of 
cases, the patient being enabled to read the finest type with 
the correcting lenses and to see sharply in the distance. 
The wearing of such powerful lenses as is necessitated after 
the removal of the lens is attended with some inconveni- 
ence, the perception of objects lying outside of the focus 
of the spectacle lens being naturally much less perfect than 

13 



194 HYGIENE OF THE EYE 

is the case in eyes from which the crystalhne lens has not 
been removed. This visual limitation, however, is very 
slight and should not detract from the proper apprecia- 
tion and recognition of the great boon which this operation 
has been to humanity. The restoration of a helpless blind 
individual to activity, efficiency and happiness is an achieve- 
ment for which humanity should be ever grateful to the 
many surgeons of many diiFerent races, whose efforts ex- 
tending over years of trial, led to the development and 
perfection of the present form of procedure. 

The operation is one of exceeding difficulty, and the 
best results are naturally attained by the most able and 
experienced. At times, however, even when performed 
by skilful operators, with the most stringent attention to 
antisepsis, and with the best of after care, inflammation 
arises in the operated eye and vision is not restored. In 
some instances this failure is due to technical difficulties 
arising during the operation, but in the majority, to some 
condition of health of the patient, which retards the heal- 
ing process and favors the development of inflammation in 
the eye. For this reason the operation is not always a 
success in those who suffer from Bright's disease, diabetes, 
tuberculosis, and certain forms of rheumatism, and in al- 
coholics, though even in such cases perfect results are often 
obtained, and the existence of such disorders are not deemed 
a positive contradiction to it. 

The careful operator will naturally avoid operating 
until any ocular complication, such as disease of the tear 
passages, which might possibly jeopardize the success of 
the operation, has been removed. 

In former years it was deemed unwise to remove a 
cataract until it was ripe, that is to say, until the entire 



CATARACT 195 

lens was entirely opaque and the eye quite blind. Later 
experience and the perfection of methods have determined 
this restriction to be unnecessary, and the rule adopted by 
most operators where both lenses are cataractous and blind- 
ness threatening, is to remove the cataract most advanced, 
as soon as the vision in the best eye deteriorates to such a 
degi'ee that reading is no longer possible or going about 
unsafe, certain technical procedures recently perfected 
rendering the removal of unripe cataracts practically as 
safe as those which are fully matured. 

From what has been said, it seems unnecessary to state 
that a cataract once successfully removed cannot return, 
it being impossible for the lens to regenerate itself. 



CHAPTER XIV 

GLAUCOMA 

The term glaucoma is used in a broad sense to cover 
the whole series of morbid changes which are produced by 
increased fulness or tension within the eye. Under normal 
conditions, the pressure in the ocular chambers which pre- 
serves the shape and tension of the eyeballs is constant, the 
balance of secretion of the intra-ocular fluid and the amount 
of blood and lymph within the eye being established by the 
drainage and escape of these fluids through proper avenues 
of exit. Should, for any reason, the balance be disturbed 
and any hindrance offered to the escape of these fluids, 
either by a stoppage in the drainage canals or by a change 
in the constitution of the fluids, in consequence of which 
their filtration powers through these canals is retarded, too 
much fluid collects within the eye and the eyeball hardens. 
As will appear presently, the consequence of this increase 
in tension is most disastrous to sight, the tissues of the eye 
being unable long to withstand the destructive effect of 
the pressure exerted upon them. 

Glaucoma exists under a variety of forms, which, how- 
ever, do not differ in their essential nature, but only in the 
degree and rate of increase of the tension. In what is desig- 
nated as chronic glaucoma, the pressure increases very 
slowly, without giving rise to any inflammatory symptoms ; 
in subacute glaucoma the increase of tension comes on in 
a succession of attacks, which are attended with marked 
symptoms of congestion of the eyeball and more or less dis- 
turbance of vision. In acute fulminating glaucoma, the 

196 



GLAUCO]VL\ 197 

rise in tension is rapid and maintained and is attended with 
total blindness in the affected eye. 

Glaucoma is further designated as primary or second- 
ary. In the former, the disease arises independently of 
any other affection within the eye, while in the latter it is 
dependent upon or, rather, occurs as a sequel to some pre- 
existing ocular disease. Secondary glaucoma needs no 
further comment here, being of too technical a nature to 
describe in a work of this kind. 

Primary glaucoma is, however, of paramount impor- 
tance to the layman, and the necessity of an appreciation 
of its chief characteristics even more important perhaps 
than that of cataract. Sight may be lost from cataract 
and may be regained by operation, but the loss of vision 
from glaucoma is usually incurable, and cannot be re- 
gained. 

While in the acute forms there are inflammatory symp- 
toms which warn the patient of the existence of disease 
within the eye, in the more common chronic form such 
warning symptoms are absent, the patient imagining the 
slight visual disturbance from w^hich he suffers demands 
but stronger glasses for its correction. Should an optician 
be consulted, instead of an oculist, as happens not infre- 
quently, the disease if in its incipiency will be overlooked, 
a pair of glasses prescribed, and perhaps even a second and 
a third pair at later intervals, as the loss of sight pro- 
gresses and the failure of the lens to give requisite vision 
proves inadequate. If medical aid is then sought, the dis- 
ease has often progressed so far that but little can be 
done to check the disease and retain the vision that re- 
mains, for the sight which has been once lost from chronic 
glaucoma cannot be regained. 



198 HYGIENE OF THE EYE 

The warfare waged in so many states by medical men 
to restrain the activities of opticians and optometrists, has 
been entirely with the view of protecting the public against 
such disasters as arise from this prescribing of glasses b}^ 
those untrained in all the branches of ophthalmic science. 
The recognition of glaucoma in its early stages demands 
a high degree of knowledge and training in this branch of 
medicine, and unless the disease be recognized and treated 
properly, more or less loss of sight is sure to follow. 

If treated early, the cure of the condition may be at- 
tained in many cases, and in others the sight saved for 
many years. 

Operative measures will save nearly all cases of the 
inflammatory forms, provided they are instituted early in 
the course of the disease. The danger in the inflammatory 
varieties resides in the failure to obtain prompt operative 
relief, either in consequence of delay in securing the ser- 
vices of an ophthalmic surgeon, owing to remoteness from 
medical centres, or to improper treatment administered by 
some medical man, who has mistaken the glaucomatous 
attack, on account of the attendant vomiting, for a bilious 
seizure, or for an inflammatory condition of the conjunc- 
tiva or iris. 

As has been said, chi'onic glaucoma in its initial stages 
presents nothing unusual to a casual inspection. The 
ophthalmologist will detect, however, an unusual shallow- 
ness of the anterior chamber and perhaps a slightly dilated 
pupil. The ophthalmoscope will also reveal a commence- 
ment of depression or cupping of the head of the optic nerve. 
Physiologically, the hole in the sclera which permits the pas- 
sage of the optic nerve into the ej^e is the weakest part of the 
eye, and is therefore the first to give way when the intra- 



GLAUCOMA 199 

ocular tension becomes increased. In consequence of the 
pressure, the head of the optic nerve is pushed back, and a 
cup-shaped depression formed, vision being seriously com- 
promised by the damage inflicted upon the nerve fibres 
as they leave the nerve to spread out over the retina. 

While in the early stages, those who suffer from glau- 
coma may not be aware of a visual disturbance other 
than difficulty in reading, the ophthalmologist is frequently 
able to map out blind spots and other losses in the visual 
field. 

The tonometer, an instrument devised to record the 
hardness of the eye, also enables the ophthalmologist to 
properly estimate the intra-ocular tension and gives posi- 
tive proof of its elevation. 

If untreated, the chronic glaucomatous eye slowly in- 
creases in hardness until the rise in tension is even per- 
ceptible to the examining finger. The pupil becomes more 
widely dilated, and the cupping in the head of the nerve 
deeper and deeper. After varying lengths of time, total 
blindness ensues, and a greenish hue is imparted to the 
pupil, whence the disease received its name. 

The diagnosis of the inflammatory form of glaucoma 
presents few difficulties, the sudden rise in tension being 
attended with signs which are absolutely characteristic to 
the skilled observer. A deep zone of congestion suiTounds 
the cornea, the pupil is dilated, and unless the haze which 
soon spreads over the cornea prevents, the cupping of the 
nerve is demonstrable. In some cases, hemorrhages occur 
in the retina. Vision is rapidly lowered, and if the af- 
fected eye be directed toward a light, on account of the 
haze of the cornea, circles of various colors are seen about it. 

There is usually great pain in the eye, which often 



200 



HYGIENE OF THE EYE 



radiates into the temple and down the side of the nose, and 
vomiting is provoked with other signs of severe physical 




Fig. 71A. — Microphotograph of anterior part of a normal eye, showing the main channel 
of escape for the intra-ocular fluid (a), i.e., tiie angle of the anterior chamber, open. (After 
Collins in Posey and Wright; Lea & Febiger.) 




Fig. 71B. — Microphotograph of anterior part of a glaucomatous eye, showing this angle (a) 
closed. Iridectomy opens this angle by removal of part of the iris. (After Collins in Posey 
and Wright; Lea & Febiger.) 

depression. Sight may be entirely lost in a few hours, 
never to be regained, unless operative measures are insti- 
tuted. In the subacute variety, a remission in symptoms 



GLAUCOMA 201 

usually follows after some hours, in which event the ten- 
sion falls and the eye slowly regains its normal appear- 
ance, vision mayhap being thoroughly restored. 

While there is some difference of opinion regarding 
the best means of conserving vision in chronic glaucoma, 
it has long been established that some form of operative 
procedure is demanded, and demanded with as little delay 
as possible, in all forms of inflammatory glaucoma. 







Fig. 72. — Incising the eye at the corneal margin for iridectomy. 

The chief avenue of exit of the intra-ocular fluid is 
through a porous space at the angle of the anterior cham- 
ber, where the root of the iris and cornea join. By reason 
of the rise in tension in glaucoma, this space is blocked, the 
base of the iris becoming adherent to the neighboring 
cornea. The aim of operators, therefore, is to open this 
space, either by removing a section of the iris, or by cutting 



202 



HYGIENE OF THE EYE 



a hole into the eye in this position, to obtain a permanent 
area of filtration. Various modifications of these two 
methods of procedure, of iridectomizing (Figs. 71, 72, 73, 
and 74) and trephining the eye, as they are called, are 
in vogue, operators the world over being busily engaged 
in perfecting methods which will best maintain a porous 
space through which the fluids may escape from the eye. 
Naturally, various medicinal measures, both general and 
local, are also of value. 




Fig. 73. — Iridectomy; a portion of the iris has been drawn through the cut in the sclera, 
and excised close to its ciliary att^^chment by one or more snips of the scissors held parallel 
to the scleral incision. 

The results of these operations are often but short of 
marvellous, eyes which have been blind for hours, indeed, 
in some instances for several days, being restored to per- 
fect visualizing organs. The world is indebted to von 
Graefe, the famous German ophthalmologist, for this boon 
to humanity, this distinguished surgeon being the first, in 
1856, to restore vision in eyes blind from glaucoma by 
iridectomy. Until von Graefe's discovery, blindness from 
glaucoma was incurable. 



GLAUCOMA 203 

While the results of operation are not so brilliant in 
chronic glaucoma as in the inflammatory varieties, treat- 
ment for this condition is far from hopeless, and vision may 
be retained in many cases as long as life lasts, either by 
some one of the forms of operation just mentioned, or by 
the continuous use of myotics. Myotics are drugs, such as 
eserine and pilocarpine, which have the property of con- 
tracting the pupil and pulling the base of the iris away 
from the cornea, thereby opening up the filtration angle 
of the eye. The author has long been an advocate of the.ir 
use and has reported cases where vision has been main- 




FiG. 74. — Coloboma of iris after iridectomy. 

tained for more than 20 years by their continuous em- 
ployment. As their use necessitates an intelligence and 
steadfastness which is not possessed by all classes of society, 
and the more or less constant oversight of an ophthalmol- 
ogist, this method of treatment is not usually resorted to 
in all hospital cases. Operation is also reserved for cases 
in which the use of myotics fails to control the disease. 

Patients should be enjoined to follow the regimen as 
to the curtailed use of the eyes, exercise in the open air, 
etc., already described as applicable to cataract cases. Par- 
ticular care should be given to the adjustment of the vascu- 



204 HYGIENE OF THE EYE 

lar system and the lowering of a too high blood-pressure. 

Glaucoma is a disease of middle life, true primary 
glaucoma being but rarely met with earlier. Its cause has 
never been accurately determined, though there is good 
evidence that eyes with lenses relatively too large for the 
circumlental structures about them are particularly pre- 
disposed to the disease. Arterial sclerosis has been thought 
to exert a causative influence, also gout. Uncorrected eye- 
strain and the overuse of the eyes by faulty illuminants 
are factors in some cases. An hereditary tendency can be 
traced in a number of instances. The Hebrew race is espe- 
cially liable to be affected. 

In concluding this chapter, the author would make an 
earnest plea for a wider dissemination of knowledge re- 
garding the prevalence and dangers of glaucoma among 
the laity. Treatment to be efficacious must be early ad- 
ministered, and the likelihood of glaucoma being over- 
looked in its initial stages, when in the event of failing 
vision, opticians and optometrists are consulted instead of 
qualified medical practitioners, must be recognized, and 
the possibility of danger arising from such examinations 
thoroughly appreciated. 



CHAPTER XV 

THE PARTICIPATION OF THE EYE IN DISEASES 
OF THE GENERAL SYSTEM 

The eye is part, and a very important part, of the gen- 
eral organism and participates in greater or lesser measure 
with many, indeed if not all, of the various disorders and 
diseases which affect the body. By reason of its par- 
ticularly intimate association with the brain and nervous 
system, there is scarcely any affection of these structures 
without ocular implication, indeed the initial symptoms of 
many of the most important of the morbid processes occur 
in the eye, and it frequently is the lot of the ophthalmologist 
to be the first to discover the existence of some serious 
disease of the brain or spinal cord, which had hitherto been 
unsuspected, both by the patient and his family physician. 
A peculiarity^ in the behavior of the pupil excites the sus- 
picion of locomotor ataxia, and the discovery by the ophthal- 
mologist of a swelling of the optic nerve removes all doubt 
as to the causation of the headaches from which relief may 
be sought, and leads to the detection of a tumor of the brain. 

The general practitioner judges of the state of the 
blood-vessels and of the circulatory system of his patient by 
noticing the condition of the blood-vessels, as it is mani- 
fested in the color of the lips and nails, and in the general 
appearance of the skin. The force and power of the cir- 
culation is determined by the pulse, by an examination of 
the heart, and by instrumental measurement of the blood- 
pressure. The eye specialist, however, by means of the 
ophthalmoscope, can look directly into the eye and actually 

205 



206 HYGIENE OF THE EYE 

observe the blood-vessels themselves. Since the discovery 
of this instrument not only has much which was obscure 
concerning local affections of the eye itself been explained, 
but great aid has been afforded the general practitioner in 
his diagnosis of diseases of the general system. The exist- 
ence of so-called hardening of the blood-vessels, and un- 
suspected diseases of the kidneys, liver and other organs 
have frequently been brought to light by its use. The 
obstetrician may be warned by the ophthalmologist of evi- 
dences of the insidious poisoning of pregnancy before other 
positive signs of this condition are manifest and may in- 
augurate treatment which will save his patient from the 
not infrequent fatal accidents of childbirth. 

The more skilled and experienced the examiner, the 
wider will be the revelations and interpretations of his 
ophthalmoscopic examinations. How erroneous is it, there- 
fore, for individuals to fail to avail themselves of all that 
such examinations may reveal, when ocular aid is deter- 
mined upon for the relief of troublesome symptoms. The 
ability to use the ophthalmoscope understandingly and 
to interpret its findings properly presupposes a thor- 
ough medical training, and a knowledge of the various 
pathological states of the body is only to be acquired by 
years of study of diseases of the general system as well as 
those of the eye. The ophthalmoscopic examinations by 
others than physicians, therefore, examinations by optome- 
trists, so called, and opticians, can only be superficial, and 
the interpretations of their discoveries vicarious. 

Anemia. — Diseases of the blood generally give rise 
to changes in the blood-vessels of the retina, and in the 
retina itself, which are readily observable by the ophthal- 
moscope. In chlorosis, a form of ansemia observed in 



DISEASES OF THE GENERAL SYSTEM 207 

young women with menstrual disorders, these changes may 
be very pronounced and the involvement of the optic nerves 
and attendant hemorrhages into the retina may seriously 
compromise vision. The author has recorded several such 
cases in which only the most rigorous treatment averted 
blindness. 

The insufficient nourishment afforded the ocular 
muscles in anaemia is at times productive of symptoms of 
fatigue following the close use of the eyes, and proper tonic 
treatment must be added to the functional correction of 
any existing refraction error before relief is obtained. In- 
deed, in many instances the recognition and treatment of 
anaemic conditions by hygienic and medical measures will 
often remove the necessity of prescribing glasses. A cer- 
tain dryness and congestion of the conjunctiva is observed 
at times in angemic individuals, which resists local treat- 
ment and only yields after the administration of iron and 
similar tonics. 

The retina participates in the severe implication of the 
general system which accompanies that rather rare form 
of disease, permcious ancemia; indeed, the occurrence of 
retinal hemorrhages in a long-continued anaemia without 
adequate cause often establishes the diagnosis between a 
simple and pernicious type of the blood disease. In 
leukcemia, another grave form of anaemia, the ophthalmo- 
scopic changes are very striking and significant, and may 
first call attention to the existence of the disease. 

Simple loss or diminution in the quantity of the blood 
is very rarely followed by ocular changes, the additional 
predisposing factor of impoverished blood being seemingly 
required to bring about changes within the eye. If the 
loss of blood is dependent upon disease of some organ. 



208 HYGIENE OF THE EYE 

such as the stomach or womb, serious disturbance of the 
optic nerve and retina not infrequently follows, this being 
especially the case when hemorrhages are repeated. 
Hemorrhages from the lungs are much less apt to occa- 
sion ocular changes than those from the organs just 
mentioned. 

Rhachitis — ^RiCKETS. — By reason of the impoverish- 
ment of the general system, which is a constant concomi- 
tant of this disease, ulcers of the cornea andr inflammatory 
conditions of the conjimctiva occasionally arise. The most 
important change wrought in the tissues of the eye is, 
however, a peculiar form of opacity of the crystalline lens, 
which may be either present at birth or arise shortly after- 
wards. This particular form of opacity is limited and in- 
volves the zone of the lens situated between its centre and 
its circumference and is designated as " zonular " or 
" lamellar " cataract. Vision is greatly interfered with 
and the removal of the lens by operation is usually neces- 
sary before sufficiently clear vision is obtained to enable 
the individual to read small type. 

Disease of the Blood-vessels. — In no other dis- 
eased state of the body has the ophthalmoscope afforded 
such aid in diagnosis as in the detection of changes in the 
blood-vessels of the retina, and but few general practi- 
tioners fail to avail themselves of the opportunity afforded 
by the ophthalmoscope of actually observing the retinal 
blood-vessels. It has been estimated by an eminent 
authority that changes in the retinal vessels occur in nearly 
half of all patients with general arterial sclerosis. 

The importance of the early interpretation of these 
vascular changes ma^^ be impressed more firmly, when it 
is realized that they are part of the general vascular disease 



DISEASES OF THE GENERAL SYSTEM 209 

which not infrequently eventuates in chronic kidney disease. 

The pulsation in the retinal vessels can be plainly ob- 
served by the ophthalmoscope, and certain affections of the 
heart accompanied by marked changes in the pulse can be 
readily diagnosed by a glance into the eye. 

Cardiac disease may also manifest itself within the eye 
by the formation of a clot in its principal blood-vessel, with 
resultant blindness, which is usually fortunately limited to 
one eye. The occurrence of repeated small hemorrhages 
in the conjunctiva and retina in individuals on the far side 
of 65 years is a bad sign for longevity, such occurrences 
being frequently the precursors of cerebral apoplexy. 

Diseases of the KmxEYS (Bright^s Disease) . — The 
ocular changes excited by kidney disease are of paramount 
importance and, occurring at times before other symp- 
toms have made themselves manifest, in some cases even 
before albumin has appeared in the urine, the oculist is 
frequently the first to discover the existence of this dread 
malady. By far the greatest number of cases exhibiting 
retinal changes occur in chronic disease of the kidneys, but 
the acute inflammations of these organs, which at times 
accompany scarlet fever and pregnancy, and less frequently 
those secondary to intermittent fever and chronic lead 
poisoning, may also evoke them. Both eyes are usually 
affected. It has been estimated that retinal changes dis- 
coverable by ophthalmoscopic examination are found in 
about 20 per cent, of all cases of chronic disease of the 
kidneys. The average age at which the retinitis occurs 
is over 40 years, varying, however, between 5 and 78 years. 
The far greatest number, however, occur between 40 and 50 
years of age. 

The retinitis of kidney disease is more or less diag- 

14 



210 HYGIENE OF THE EYE 

nostic (Plate II, C) , that is to say, the hemorrhages and ex- 
travasations which are found there as part of this general 
disease assume more or less definite forms, so that the 
skilled observer is, as a rule, able to determine the exist- 
ence of the kidney lesion by even a cursory glance into 
the eye. 

Ophthalmoscopic changes accompanying disease of the 
kidneys have a serious import, as they usually indicate a 
marked progression of the disease, and indicate that unless 
the greatest care is exercised, but a few years of life remain. 
A carefully regulated manner of living, with the best of 
medical care, may, however, prolong life for many years. 
The author has in mind the case of a man of advanced 
years who is still in fair health, in whom albuminuria, 
retinal changes and other evidences of renal disease have 
been present for at least eighteen years. 

The extent to which vision is affected depends naturally 
upon the extent and location of the changes within the eye. 
Total blindness is rare, though vision is usually so seri- 
ously compromised that the ability to read fine type is lost. 

The loss of vision due to structural change within the 
eyes must not, however, be confounded with the transient 
attacks of total blindness which occur in kidney disease and 
which are of urgemic origin, being dependent not upon 
changes within the eye, but due to an irritation of the 
brain centres governing vision by poisonous substances cir- 
culating in the blood, the product of the kidney disease. 

Transient puffiness of the lids, due to an infiltration of 
the tissues of the lids, may occur in the early stages of 
nephritis. Permanent oedema or thickness is a later mani- 
festation of the disease. 

Diabetes. — In this disease, which is characterized by 



DISEASES OF THE GENERAL SYSTEM 211 

the occurrence of many obscure symptoms in the nervous 
system and elsewhere in the organism and by the more or 
less constant presence of sugar in the urine, the involvement 
of the eyes is of frequent happening. The ocular mani- 
festations are also varied, for nearly all the tissues of the 
eye may be affected. The most important, however, are 
the changes which occur in the ciliary muscle, in the lens 
and in the retina, for it happens not infrequently that the 
ophthalmologist is the first to call attention to the existence 
of diabetes, by the discovery of the more or less character- 
istic disturbances which the abnormal quantity of sugar in 
the economy occasions in those structures. 

It has been asserted that eye changes manifest them- 
selves at some period during the progress of a case of 
diabetes in at least two-thirds of all cases. Such manifesta- 
tions may occur as early as nine years, though the greatest 
proportion are observed between 60 and 70 years of age. 

The changes occasioned by diabetes in the ciliary muscle 
manifest themselves in disorders of the accommodation, 
interfering very markedly with reading and all close use of 
the eyes. Xot infrequently, individuals unaware of their 
having diabetes, consult the ophthalmologist for stronger 
glasses, on account of a paralysis, more or less constant, 
in the muscles of accommodation. 

Even more significant is the opacification of the crys- 
talline lens which occurs in diabetes, with a frequency vari- 
ously estimated from 4 to 25 per cent. Unlike haze of the 
lens or cataract from other causes, apart from the con- 
genital varieties and those which arise from injuries, dia- 
betic cataract may occur at any age, being often seen in 
subjects as young as ten years. Another point of dis- 
similaritv between this varietv of cataract and all other 



212 HYGIENE OF THE EYE 

forms of haze of the lens, is its spontaneous disappearance 
at times, and the influence of proper treatment in lessening- 
its density. 

So frequent is the association between diabetes and 
cataract, that it is a rule of eye surgeons to test the urine 
of all cases presenting lenticular opacities for sugar. Its 
discovery, while not contra-indicating the removal of the 
cataract, for in many instances this may be accomplished 
without accident, always arouses anxiety in the operator, 
for at times complications occur which seriously mar the 
success of the operation. 

The retinal manifestations consist in hemorrhages and 
extravasations which may seriously affect vision. Often 
however, these yield to treatment and perfect sight is 
regained. 

Infectious Diseases. — Although nearly all fevers re- 
sulting from infectious processes may exhibit ocular symp- 
toms at some time or other in their course, it is beyond the 
scope of this volume to detail all such complications. It 
will suffice to refer briefly to the disorders the eyes are 
prone to suffer in several of the more common of these 
conditions. 

As is well known, the eye symptoms of measles are 
veiy marked. In the early stages the dread of light 
and increased lachrymation often arouse the suspicion of 
the true nature of the fever, and these symptoms, with 
the attendant catarrhal inflammation of the conjunctiva 
and the occurrence of ulcers on the cornea, often con- 
tinue long after the fever has abated. Unless the eyes 
receive suitable local treatment and the room is properly 
darkened, the cornea may become the seat of ulcers, which 
by occasioning later scar formation or even actual perfora- 



DISEASES OF THE GENERAL SYSTEM 213 

tion of that membrane, may seriously jeopardize sight 
throughout the rest of hfe. Thousands of children have 
had their lives marred by neglect and injudicious treatment 
during an attack of measles. All direct sunlight should be 
shut out of the sick-room as long as fever is present, and 
only as much reflected light permitted as may be tolerated 
without pain. 

In consequence of the weakness of the ocular structures, 
all near use of the eyes should be prohibited during con- 
valescence, being resumed only after the general system 
has thoroughly recovered from the effects of the fever. 

If corneal ulceration occur during the course of the 
treatment, the practitioner in charge should seek the aid of 
an ophthalmologist at once, and the advice of the specialist 
should also be sought during convalescence, if any signs of 
inflammation about the eyes persist during this period. 

Too often the close use of the eyes is permitted earlier 
than is proper, fostering the development of near-sighted- 
ness and astigmatism. If errors of refraction are found to 
be present after convalescence, it may be desirable to cor- 
rect such errors by glasses, until the eyes have regained full 
strength. 

Scarlet Fever. — Like other febrile conditions, scarlet 
fever may give rise to catarrhal conjunctivitis and marked 
ulceration of the cornea. As a rule, however, the eyes 
suffer but little in this disease, though inflammation of the 
optic nerve and retina may be set up by complicating dis- 
ease of the kidneys. Xot infrequently, eye-strain is com- 
plained of during convalescence, and may persist after the 
general health is reestablished. The importance of the 
avoidance of too early use of the eyes and the correction of 
all errors of refraction by suitable glasses is apparent. 



214 HYGIENE OF THE EYE 

Diphtheria. — Apart from a destructive form of con- 
junctivitis, which sometimes, though rarely, affects the hn- 
ing membranes of the Hds, and certain forms of paralysis of 
the eye muscles, which are also of infrequent occurrence, 
the ocular lesion most frequently met with is the partial or 
complete paralysis of one, or what is more usual, of both 
ciliary muscles. This paralysis, which totally disables the 
eyes for all close work, may follow even slight attacks of 
diphtheria. The paralysis supervenes from 3 to 6 weeks 
after the appearance of the disease, persists for weeks or 
months and finally disappears, even in untreated cases. 
Convex lenses, to supplement the inactive lens, by reason of 
the paralysis of the muscle controlling it, are necessary for 
all near work as long as the action of the ciliary muscle is 
suspended. 

Small-pooc. — Before the days of vaccination, it was 
estimated that 35 per cent, of all cases of blindness were 
due to this disease, whereas to-day the proportion ranges 
from between 2 to 3 per cent. The eruption of small-pox 
frequently occurs upon the lids, whence it spreads to the 
cornea, causing ulceration and the production of dense 
scars, or even perforation of that membrane. So virulent 
is the poisoning of the system by this noxious disease that 
almost all of the ocular structures may take part in the 
general infection, and for the sake of conservation of vision, 
if for no other reason, society should cooperate with the 
State in the enforcement of vaccination laws and the com- 
pulsory report and segregation of all cases. 

Carelessness in vaccinating may result in the accidental 
vaccination of the lids by fingers soiled with the virus, and 
the loss of the eye may follow precisely as if the resultant 
pustule had been part of the general infection. 



DISEASES OF THE GENERAL SYSTEM 215 

At times, in children and the weak, a purulent, though 
mild, inflammation of the cornea and conjunctiva may be 
excited by an ordinary vaccination, which demands treat- 
ment and exclusion of light for some weeks following the 
inoculation. 

Erysipelas. — This infection, usually involving the skin 
of the head, may spread to the lids, causing abscesses and 
subsequent deformities in these structures, and sometimes 
ulceration of the cornea. The orbital tissues may also be 
invaded, giving rise to inflammation of the optic nerve, with 
resultant blindness or serious impairment of vision. At 
times the inflammation spreads from the orbit to the brain, 
and death ensues from meningitis or clot formation. 

Typhoid Fever. — Fortunately, serious ocular lesions, 
though sometimes observed in the later stages of the dis- 
ease, are rare in this not uncommon fever. Corneal ulcers 
and attacks of conjunctivitis common in all febrile diseases 
are, however, occasionally observed. More important for 
consideration in a work of this kind is the relaxation of all 
the muscles of the eyes which accompanies the long con- 
valescence, and the importance of the avoidance of all ocular 
strain and the correction of all refraction errors until full 
health has been regained. 

Malaria. — jNIore or less typical ulcers of the cornea may 
complicate malaria, but by far the most important lesions 
affect the uveal tract, retina and optic nerve. 

Influenza. — All of the ocular structures may be in- 
volved by this bizarre disease, but none are sufficiently con- 
stant to render them typical of it. Perhaps the most com- 
mon are those resulting secondarily from diseases of the 
adjacent air cavities which are connected with the nose. 
The neuralgic pain and tenderness of the eye and the parts 



216 HYGIENE OF THE EYE 

about the eye are usually dependent upon the involvement 
of these structures and can be relieved only by appropriate 
nasal and sinus treatment. 

Whooping-cough. — Not infrequently, due to the con- 
gestion of the ocular tissues by the spasmodic cough and 
the violence of the effort, the sclera of both eyes may be- 
come deeply suffused with blood, occasioning no little alarm 
to the layman. The hemorrhage, however, is superficial, 
just below the conjunctiva, and is quite harmless, being 
totally absorbed in a few weeks. 

Mumps. — Like all the infectious fevers, mumps may in 
rare instances give rise to serious inflammation of the optic 
nerve and retina. Ordinarily, however, the eyes are un- 
affected. Rarely the lachrymal glands, by an extension of 
the infective process to other glandular structures, such as 
is observed more commonly in the testicles, may be affected 
and pronounced swellings may appear under the outer por- 
tion of each orbital ridge. 

Cholera. — In consequence of the severe emaciation 
wrought by this now fortunately rare disease, the eyes are 
frequently seriously involved. The globes sink back into 
the orbits, and the patient lying semiconscious, with lids 
but partially closed, dust collects on the devitalized cornea 
and extreme ulceration follows. 

Leprosy. — Leprosy, also a rare disease in the United 
States, has definite ocular symptoms, the leprous nodules 
forming on the lids and at times on the eyeball. Deformi- 
ties of the lids and dense opacities of the cornea are fre- 
quent sequelse. 

Tuberculosis. — It is not remarkable that this wide- 
spread and common infective process should have frequent 
ocular manifestations. The eyes of children are most liable. 



DISEASES OF THE GENERAL SYSTEM 217 

but the lesions may appear at any age in individuals whose 
resisting power to the specific organism carrying the dis- 
ease is weak, as well as those unduly exposed to infection. 
The most striking ocular lesions occur in the negro, a race 
whose resisting power to the disease is extremely low. 
Xearly all the parts of the eye may be affected, but the 
cornea, iris, and choroid are chiefly liable. 

In rare instances, the eye may be the primary seat of 
tuberculosis. Usually, however, the ocular manifestations 
are secondary to tuberculosis elsewhere in the system. 
When seated in the iris, the tuberculous masses present a 
very characteristic appearance, rising out of the dark tis- 
sue of the membrane as small grayish- white cone-shaped 
masses, resembling small sugar loaves. The discovery of 
similar though smaller nodules in the choroid, by means of 
the ophthalmoscope, may establish the diagnosis of tuber- 
culosis in cases of obscure meningitis, though the value of 
this discovery from a prognostic or therapeutic standpoint 
is minimized by the fact of their occurrence so late in the 
disease. 

The most common seat of tuberculosis is in the cornea, 
and especially in the cornea of children, giving rise to the 
condition already described as phlyctenular or scrofulous 
keratitis. As the treatment and sociological features of 
the disease were fully dwelt upon at that place, a repetition 
is unnecessary. It is only necessary to emphasize that, as 
with tuberculosis elsewhere in the system, personal hygiene 
and h^^gienic surroundings have much to do with the pre- 
vention and cure of tuberculosis, and the ophthalmologist 
who essays to cure local manifestations of tuberculosis must 
avail himself not only of proper local medicament, but also 



218 HYGIENE OF THE EYE 

of all that modern science has taught may be done to com- 
bat and control this prevalent infection. 

Yenereai. Diseases. — Gonorrhoea. — This disease, af- 
fecting the genital apparatus of both male and female, is 
of particular importance to the eye surgeon in as much as 
fully 25 per cent, of the blind owe their affliction to it. 
Affecting at some time or other in their^J^ives from 60 to 
80 per cent, of young men and a considerable proportion 
of women, gonorrhoea is a menace to society which demands 
the most careful consideration for its control and elimina- 
tion. How this may be accomplished is still a matter of 
debate, but undoubtedly one of the most potent agents for 
its combat is a dissemination among the laity of a knowl- 
edge of its prevalence and dangers. No boy or girl should 
be allowed to approach the age when they may be exposed 
to its dangers without some knowledge of its existence and 
should be admonished as to the necessity for purity if for 
none other than sanitary reasons. As the effects of this 
disease have been treated so thoroughly elsewhere, it will 
only be necessary to repeat in this chapter that gonorrhoea 
is the causal factor in most cases of inflamed eyes of infants 
at birth (see p. 129). Adults lose their sight by carrying 
the noxious organisms from the infected genital organ to the 
eye by the fingers or through the medium of a soiled hand- 
kerchief. Less serious ocular complications arise in conse- 
quence of a systemic poisoning from gonorrhoea and an 
implication of the tissues of the eye through the blood. 

Of equal importance from a social as well as a medical 
aspect is the effect of syphilis upon the eye. This loath- 
some disease, affecting probably 10 per cent, of the in- 
habitants of all the larger cities of the world, is an infectious 
process, caused by a definite germ and readily transmissi- 



DISEASES OF THE GENERAL SYSTEM 219 

ble in most of its forms to others. All the tissues of the 
body may be affected by it, and its course, if treatment be 
inefficacious, is terminated only with the life of the 
individual. 

Although syphilis is usually acquired in a much less in- 
nocent manner than the following, the notes of a case cited 
in a popular text-book on syphilis is descriptive of one of 
the modes of contagion: 

" A young and upright man kisses a girl at an evening 
frolic. Shortly after he becomes engaged to marry another 
girl. A supposed fever sore upon his lips causes him no 
anxiety until a similar sore appears upon the ej^elid of his 
betrothed and an eruption breaks out upon his own body. 
Then to the family physician, who finds both syphilitic." 

Acquired syphilis begins after a few weeks' incubation 
with a sore or chancre, as it is called, at the point of in- 
oculation. A few weeks later, the secondary lesions put in 
an appearance. These take the form of an eruption upon 
the skin or of acute inflammations of various organs. After 
these initial manifestations have disappeared, tertiary 
lesions develop, as a rule in the deeper structures of the 
body, and while they are often malignant in nature and 
make great inroads upon the tissues of the body, they are 
not infectious like the two preceding stages. 

In hereditary syphilis, the disease is transmitted by 
either parent and attacks the progeny with varying degrees 
of virulence, generally, however, producing characteristic 
deformities of the teeth, of the skull and the remainder of 
the skeleton. 

As has been learned by a perusal of earlier chapters, all 
parts of the eye are susceptible to the poison of syphilis 
and no age is exempt from its ravages. S3^philis frequently 



220 HYGIENE OF THE EYE 

attacks the nervous system, and by involving centres in 
the brain which control visual perceptions and ocular move- 
ments, as well as parts of the spinal cord and the nerves 
supplying the ocular muscles themselves, is indirectly re- 
sponsible for many complicated and serious affections of 
the nervous and motor systems of the eyes. 

The control of syphilis demands even a more rigorous 
campaign of education and enforced sanitation than that of 
gonorrhoea, and the suggestions given to parents and edu- 
cators in the paragraphs dealing with gonorrhoea are em- 
phasized as being of even greater importance in safeguard- 
ing the young against the evils of this widespread disease. 

Diseases of the Sexual Organs. — In addition to the 
changes observed in gonorrhoea and sj^philis which result 
usually primarily from diseases of the sexual organs, at- 
tention may be called, in the first place, to the ocular diseases 
which accompany the various forms of imbalance in the 
vascular and nervous systems which are excited by abnor- 
mal menstruation. Latent inflammatory conditions of all 
kinds are frequently made manifest by the menstrual 
period, particularly if this be at all deranged or irregular. 
Styes, conjunctivitis, and keratitis often recur, and even 
more serious inflammations of the deeper structures of the 
eye may be brought into activity. At the time of the meno- 
pause, hemorrhages into the retina are not uncommon, and 
an irritability of the nervous system provoked which often 
manifests itself in a train of asthenopic phenomena. Under 
such conditions, it is often impossible to prescribe glasses 
which will enable the eyes to be used with entire comfort. 
The conjunctiva is also congested and irritable and the 
eyes water and are sensitive to light. Glaucoma, or hard- 
ening of the eyeball, may appear at this time. 



DISEASES OF THE GENERAL SYSTEM 221 

In pregnancy, the eyes are not infrequently the seat of 
pigmentation, and if there be any sublying weakness of the 
system, such as anasmia or kidney disease, inflammatory 
conditions within the eye may be awakened which seriously 
complicate the normal course of labor. On account of the 
excessive tissue changes which accompany pregnancy, the 
kidneys, liver and other organs are at times unequal to the 
task put upon them, and toxsemia or blood-poisoning re- 
sults. This manifests itself in early pregnancy by per- 
nicious vomiting, later in persistent headache, failing vision, 
motes, stomach pain, and restlessness. Examination of 
the urine for albumin being negative, the obstetrician is at 
times thrown off his guard, and the symptoms are re- 
garded as local and of no particular import, until convul- 
sions occur. It is in cases such as these, that an ophthalmo- 
scopic examination is of particular value, the discovery of 
retinal hemorrhages and exudates rendering the diagnosis 
of toxaemia positive, and indicating the necessity for its 
proper treatment. 

It is only recently that obstetricians have appreciated 
that changes in the retina which have been occasioned by 
kidney disease and are almost certainly diagnostic of kid- 
ney disease, may precede the presence of albumen in the 
urine, and that the ophthalmoscope may give evidence of 
disease of organs other than the kidneys, which has been 
excited by the toxaemia of pregnancy. While the kidney 
condition which arises in pregnancy is an acute one, in 
many instances it is engrafted upon a chronic condition, 
which has existed prior to pregnancy. The ophthalmo- 
scopic examination under these conditions reveals in most 
instances disease of the retinal vessels and informs the ob- 
stetrician of the true condition of affairs. The usual oph- 



222 HYGIENE OF THE EYE 

thalmoscopic picture of the kidney disease of pregnancy is 
that of other varieties of Bright' s disease, consisting of 
well marked inflammation of the optic nerves and retina, 
with extravasations and hemorrhages. This form of retin- 
itis occurs most frequently with the first pregnancy, but may 
complicate later pregnancies also. The diagnosis of toxsemia 
once made, the question of saving the life of the mother 
must now be considered, as ocular symptoms occurring in 
the course of pregnancy only arise in the event of a pro- 
found autointoxication and the alternative of inducing labor 
artificially must be weighed, the ocular examination being 
frequently made the crux on which the decision is rendered. 
It is generally held that in all cases which exhibit ocular 
symptoms in the first six months of pregnancy, labor should 
be induced at once, while women in whom the symptoms 
appear in the last seven weeks should be carefully watched, 
unless the retinal lesions are very severe. For under these 
latter conditions the social condition of the parents and 
the desire of the mother to have a child must be taken into 
account, especially as the artificial induction of labor under 
such circumstances does not always improve vision, and as 
the life tenure of such women, like that of other subjects 
of B right's disease, is generally much curtailed. Twenty- 
five per cent, of such women lose their sight entirely, 29 
per cent, make a full recovery, and 47 per cent, but a par- 
tial recovery of visual acuity. 

In the general blood-poisoning which sometimes fol- 
lows later, puerperal septicaemia, septic clots may be carried 
from the womb into the eyes, causing purulent inflamma- 
tion of all the coats of the eye, with subsequent loss of 
sight. 



DISEASES OF THE GENERAL SYSTEM 223 

Infection following abortion may also result in septic 
processes in the various coats of the eye. 

During convalescence from childbirth, the need of 
glasses for the correction of even trifling errors of refrac- 
tion is often manifested. It is well, however, that the 
mother should refrain from all near use of the eyes until 
she has thoroughly recovered from the exhaustion and 
anaemia of labor. 

Birth often entails injury to the eyes of the infant. 
This, as might be expected, is particularly true when in- 
strumental delivery has been necessary. Hemorrhage into 
the orbit, tears of the lids and even of the cornea, injury to 
eye muscles, are some of the accidents which are not in- 
frequently observed. When labor is very prolonged, hemor- 
rhage may occur into the retina. 

The diseases of the conjunctiva which may originate 
during the birth of the child are considered elsewhere. 

Diseases of the Skin. — ^On account of the anatomi- 
cal and embryological relationship which exists between 
the skin and the mucous membrane of the eye and the super- 
ficial layers of the cornea, disorders of the skin frequently 
involve the eye. This is particularly true of eczema and 
herpes, and of various growths of a cancerous nature. Of 
the association of eczema with the eye, consideration has 
already been given under phlyctenular keratitis. In herpes, 
blisters may appear upon the cornea and conjunctiva, and 
occasion painful and persistent ulcers. More or less im- 
pairment of vision usually follows. The numerous glands 
in the lids render these structures peculiarly prone to in- 
flammation, and styes or inflammation of those glands and 
their surrounding tissues frequently accompany acne in 



224 HYGIENE OF THE EYE 

other portions of the face and body. At times true fur- 
uncles or boils attack the lids, causing marked tumefaction 
and redness. Rarely lice {phtliinasis) bury themselves in 
the roots of the lashes and disappear only after they are 
suffocated by applications of suitable salves. 

Dental Affections. — Abscesses in the teeth may by 
the spread of the inflammation, give rise to orbital abscesses 
and also to infectious processes within the eyeball. Other 
dental affections of a less serious nature, in consequence of 
the association between the nerve supply of the teeth and 
eyes, occasion various functional ocular disturbances, such 
as anomalies in the action of the ciliary muscle and reflex 
disturbances in the visual field, due to vascular changes in 
the retina and optic nerves. 

Diseases of the Respiratory Tract. — The mucous 
membrane lining the nose is continuous, by way of the 
lachrymal passages, with the lining of the lids, so that in 
many inflammatory conditions within the nose, there is 
more or less irritation of the conjunctiva. Furthermore, 
the orbital cavities in which the eyes are encased, are sur- 
rounded by large air spaces, the so-called " accessory 
sinuses" of the nose; which communicate with the nose 
and are lined by a continuation of its mucous membrane. 

These sinuses or cavities frequently partake in inflam- 
matory conditions, and by reason of their close anatomical 
relationship with the eyes and the nerves and muscles of 
the eyes, occasion various derangements and inflammations 
of those parts. The most frequent, perhaps, is orbital ab- 
scess. In this condition, the tissues of the orbit are in- 
flamed, the eyeball is pushed forward, the lids and con- 
junctiva swollen and vision may be lost in consequence 
of involvement of the optic nerve. In other cases, where 



DISEASES OF THE GENERAL SYSTEM 225 

there is only a stoppage in the avenue of escape of the fluids 
from the sinus into the nose, the cavity may be slowly dis- 
tended and the eyeball slowly pushed out of place, in con- 
sequence of the encroachment of the walls of the sinus into 
the orbit. In both of these conditions, unless relieved by 
operation, not only may vision be lost, but life itself, by an 
implication of the brain and its membranes. 

The ophthalmoscope is frequently of service to the nasal 
specialist in the recognition of some of the more obscure 
forms of sinus disease, particularly those situated near the 
apex of the orbit, and in relationship with the optic nerves. 
For the ophthalmoscope may reveal a congestion, and a 
study of the visual field restrictions of various kinds, which 
are more or less diagnostic of affections of those sinuses. 
Double vision may result from implication of the ocular 
muscles, and in rare cases, inflammation of the iris and of 
other ocular structures may be secondary to sinus disease. 

Adexoids and tonsillar disease, by depressing the 
vitality and exciting inflammation in the mucous membrane 
of the nose and its sinuses, may also be the indirect source 
of various forms of disease of the conjunctiva and cornea. 
The author has seen marked protrusion of both eyes caused 
by an adenoid in the pharynx of a young child, which dis- 
appeared after the removal of the growth. In like man- 
ner, tonsillar disease may be the means of introducing 
poisonous material into the system which may act deleteri- 
ously upon the tissues of the eye. The most common 
poison introduced in this way is that of rheumatism, and 
there seems to be ample evidence that many inflammatory 
conditions of the iris and of the uveal tract generally are 
dependent primarily upon disease of the tonsils. 

Diseases of the ear may interfere reflexly with the 

15 



226 



HYGIENE OF THE EYE 



ocular movements, and excite to and fro movements of the 
eyes, " nystagmus " so called (see p. 70). 

Mastoid abscess has been followed by paralysis of eye 
muscles and orbital abscesses. 

Exophthalmic Goitre (Graves' or Basedow's Dis- 
ease). — This affection, of unknown oVigin, though prob- 
ably dependent upon some disturbance of the central 
nervous system, is characterized in most cases by a group 




Fig. 75. — A case of exophthalmic goitre. (From Wilbrand and Saenger.) 

of symptoms which consist of increased frequency of the 
pulse, enlargement of the thyroid gland, or goitre (Fig. 
75 ) , the presence of certain characteristic ocular changes, 
a fine nervous tremor and nervous irritability. 

The most striking ocular symptom is the exophthalmus 
or prominence of the eyes, which is present in greater or 
less degree in almost all cases. This protrusion of the 
eyes may be so great that complete closure of the lids is 



DISEASES OF THE GENERAL SYSTEM 227 

impossible, and corneal ulceration results from exposure. 
Usually both eyes are involved; the protrusion may, how- 
ever, be limited to one. Almost equally constant Avith the 
exophthalmus are various anomalies which may be noted 
in the action of the lids. The most striking of these is the 
so-called " Graefe lid sign," which consists in ^n inability 
of the lids to follow the eyes in all downward movements. 
This and the "Dalrymple sign," the name given to an abnor- 
mal widening of the lid fissure, give to the eyes a peculiar 
staring expression, and prominence to the sclera or whites 
of the eyes, and with the exophthalmus serve to attract the 
attention of even casual observers to the existence of the 
affection. Other lid symptoms and paralyses of eye muscles 
may also occur. The slightest evidence of the disease de- 
mands instant treatment, as rest and proper medication 
may often avoid the operative measures which are necessary 
in advanced cases. 

Diseases of the Nervous System. — As has been stated 
in a former chapter, the retina is really a peripheral por- 
tion of the brain, the optic nerve serving to connect it with 
the intracranial portion of that important structure. Fur- 
thermore, of the 12 nerves emanating from the brain, which 
control the various organs of the body, six have ocular 
connections. There is scarcely an affection of the brain or 
spinal cord, therefore, without ocular manifestations; in- 
deed, often the earliest symptoms appear in the eyes, and 
the oculist is the first to discover the rudiments of what may 
become a systemic affection of the greatest magnitude. 

On account of the close anatomic relationship between 
the blood-vessels of the eye and those of the brain, it might 
be supposed that congestion of the latter would be in- 
variably followed by those of the eye. In consequence of 



228 HYGIENE OF THE EYE 

certain local regulating conditions, however, the blood- 
vessels of the eye frequently escape participation, and it is 
only when the overfulness of the cerebral blood-vessels 
has been of long standing that the ophthalmoscope reveals 
changes in the retinal circulation. When there is an in- 
crease in the intracranial pressure, hbwever, positive oph- 
thalmic evidence is the rule. The most common cause of 
such an increase is the presence of a tumor within the brain, 
and, in such an event, swelling of the head of the optic 
nerve is present in about 90 per cent, of the cases, indicat- 
ing with certaint}^ the presence of such a growth, when all 
other symptoms, save perhaps that of headache, are absent 
(seep. 178). 

Meningitis. — In the event of inflammation of the 
membranes covering the brain, not only is the optic nerve 
liable to be involved, but also the nerves supplying the 
ocular muscles. This happens in consequence of the close 
anatomical relationship of these structures with the 
meninges at the base of the brain, and their involvement 
by the exudate which is the product of inflammation in the 
membrane. Some degree of optic neuritis is present in 
some stage in almost all cases of meningitis, and although 
unfortunately it does not evidence itself early in the dis- 
ease, it is often of the utmost value in establishing the diag- 
nosis, as the ophthalmologist has this means of difl*erentiat- 
ing between typhoid fever or pneumonia, on the one hand, 
and meningitis on the other. 

The swelling of the nerve is rarely so great as that 
occasioned by brain tumor, but the effect upon vision is 
greater. Those who survive an attack of meningitis are 
frequently handicapped thereafter by great reduction in 
vision on account of unpreventable atrophy of the optic 



DISEASES OF THE GENERAL SYSTEM 229 

nerves. 3Iinute multiple tubercular nodules in the choroid 
are at times the means of diagnosing acute tubercular 
meningitis. As they appear, as a rule, only but a short 
time before death, their discovery is of but little practical 
importance. 

Hysteria. — Ocular symptoms frequently accompany 
this disorder of the central nervous system, and manifest 
themselves in a variety of ways. The mildest are those 
already designated as asthenopia, or fatigue of the ocular 
apparatus after the slightest near use. In severe cases, 
partial or even total blindness may supervene, the loss in 
vision being purely psychic and not dependent upon any 
demonstrable structural change. Such manifestations not 
rarely follow accidents of various kinds, and are often dif- 
ficult to differentiate from the casual losses assumed by 
malingerers for the purpose of recovering damage awards 
after accidents. Usually, however, a careful study of the 
fields of vision and an application of the tests known to 
ophthalmologists for the detection of fraudulent symptoms 
of blindness enable the diagnosis to be made. Drooping 
and spasm of the lids are occasionally observed in hysteria 
and at times the extra-ocular muscles show contractions. 

Insanity. — The ordinary forms of gross mental aber- 
ration are unattended with constant or dependent ocular 
signs or lesions, and as in many such states there is no evi- 
dence of anatomical change within the brain, the eyes also 
show no deviations from the normal. Conversely, loss of 
sight does not, as a rule, entail mental derangements. In 
individuals, however, who are intellectually weak, it can be 
readily understood how the loss of so important a sense as 
sight might be of serious moment and even sufficient to 
break the fragile chain of cerebration and cause insanity. 



230 HYGIENE OF THE EYE 

The author has elsewhere recorded two such cases, in which 
increasing bUndness from the development of cataracts 
caused violent mental aberration. Operation upon the 
cataracts and the restoration of vision was followed almost 
immediately by a full and permanent\ return of the mental 
processes. Similar cases have been reported by other 
operators. 

The delirium which manifests itself in about 10 per 
cent, of all cases operated upon for cataract, some days 
after the operation, is attributable to the constraint neces- 
sary for a time after the operation, to certain nutritional 
disturbances of the brain attending the enforced restric- 
tions in diet, and to the intense preoccupation which seizes 
some individuals prior to and after the operation. The 
delirium is usually transient, and yields readily to proper 
management. 

General Paralysis of the Insane. — Some of the earliest 
symptoms of this common form of insanity are ocular and 
the clinician is often enabled by the pupillary changes pres- 
ent to differentiate this serious condition from some tran- 
sient mental aberration. It would be unwise, however, to 
place too much dependence upon such pupillary changes 
alone, and it is only in conjunction with other indications 
that the clinician will attempt to interpret and draw his 
inferences from them. Hallucinations (of sight, at times, 
limited to one side of the field of vision) are common, and 
may appear early in the disease. Paralysis of the various 
eye muscles may also occur, and at times the optic nerves 
show evidences of degeneration. 

Deformities of the Skull. — The various forms of 
cranial malformation, be they microcephalia, a too small 
skull, or megalocephalia, a too large skull, are apt to be ac- 
companied by some serious disturbance of the optic nerves, 



DISEASES OF THE GENERAL SYSTEM 231 

either in consequence of pressure exerted upon the nerves 
as they pass through the optic canals narrowed by the de- 
fective development of the bones of the skull, or from some 
involvement of the tissues of the nerve by the inflammatory 
condition primarily concerned in preventing the cranial 
growth. Hydrocephalus is frequently attended with vary- 
ing degrees of visual disturbance dependent upon the 
amount of pressure exerted upon the optic nerves. 

AcKOMEGALY. — This disease, which is characterized by 
an overgro^vth of the hands and feet, and striking change 
in the facial expression, due to the overdevelopment of the 
structures composing the features, possesses almost char- 
acteristic visual symptoms. There are often marked promi- 
nence of the eyeballs, occasional palsy of eye muscles and 
frequent changes in the extent of the visual fields, the most 
common of these being areas of dimness in the centre of 
vision and loss in the outer halves of the visual fields. 

Diseases of the Spixal Cord. — Pupillary, muscular, 
and optic nerve changes are more or less common in many 
forms of disease of the spinal cord, but in locomotor ataxia, 
or tabes, the most common form of spinal disease, they 
constitute a constant and most important part of the symp- 
tom complex. The most significant of these are the pupil- 
lary symptoms, as they appear early and often supply the 
first positive indication of the nature of this serious dis- 
ease. In addition to irregularities in their size, the pupils, 
when exposed to the light, do not contract as is normally 
the case, but remain unchanged, narrowing, however, as 
the gaze is directed to some near object. Although pres- 
ent in other morbid states of the nervous system, this pupil- 
lary phenomena is an almost constant factor in locomotor 
ataxia and enables the oculist, who is not infrequently the 
first to detect it, in the routine examination of the eves for 



232 HYGIENE OF THE EYE 

glasses, to direct the attention of the patient to the necessity 
of a more extended examination of his nervous system. 

Paralysis of one or more of the ocular muscles is also 
common and a sudden attack of double vision may be the 
means of directing medical attentioii to the existence of 
tabes. Such double vision is frequently transitory, and, 
disappearing in a few days, deceives the patient as to its 
significance and gravity. In the latter stages, such palsies 
are more apt to remain constant, and are frequently dis- 
tressing and annoying to the individual. It is at this time 
that visual disturbances from optic nerve disease appear, 
and in a certain number of cases almost complete blindness 
supervenes. 

As locomotor ataxia in the vast majority of cases is of 
sj^philitic origin, it is at times amenable to antisyphilitic 
treatment. The importance of the early recognition of the 
disease is apparent, therefore, and additional demonstra- 
tion is given of the value of a careful systemic examination 
of all the parts of the eye in all refraction work, and offers 
an additional argument why such tests should not be re- 
linquished to opticians and optometrists, who are unlearned 
in medical science, and unable to detect or appreciate func- 
tional deviations which may often be significant of serious 
disease of the general system (Plate II, E). 

Infantile Paralysis; Anterior Poliomyelitis. — 
This disease of the spinal cord may also affect the brain 
and sublying nervous structures and involve the eye 
muscles. The author has reported several cases of this 
nature, in which a permanent condition of strabismus, or 
cross-eye, followed. He has also recently examined a child 
who suffered total blindness from disease of the optic 
nerves, consequent upon this mysterious scourge of 
childhood. 



CHAPTER XVI 

WOUNDS AND INJURIES 

Notwithstanding the protection afforded the eye by 
the orbit and the lids, its exposed position makes it pecu- 
liarly liable to accident, while the delicacy of its structure 
converts an injury which would be of trifling significance 
elsewhere into a matter of extreme seriousness to the hap- 
piness and earning power of the individual. The character 
and nature of eye wounds and injuries are manifold, 
ranging from the lodgement of a minute foreign body under 
the lid to the complete disintegration of the globe by a 
powder or dynamite explosion. 

Many ocular injuries befall children and the eye sur- 
geon is frequently called upon to do his utmost to save 
eyes that have been injured by perforation by forks and 
knives and scissors, by hat pins, by pens and pencils, and 
all manner of household articles. The multiplicity of ob- 
jects which can destroy sight by careless handling or im- 
proper use is appalling, and no more valuable or humane 
message can be given the layman than the plea for rigid 
and unceasing care upon the part of parents, nurses and 
all those having the care of children, that all pointed 
articles be removed from the reach of these little ones. 

When a foreign body lodges in the eye, such as a cinder 
or dust granule, the natural tendency for the patient is to 
rub the eye, not only on account of the fancied relief af- 
forded by the friction, but also in the hope of dislodging 
the offending body. This action, however, is only dele- 
terious, serving to irritate the eye and imbed the foreign 

233 



234 HYGIENE OF THE EYE 

substance more deeply. The proper procedure to follow 
in cases of this kind is to grasp the margin of the upper lid 
with the thumb and finger of the hand and to draw it out- 
ward and downward. By this simple maneuver the foreign 
body will frequently become engaged in the lashes of the 
lower lid and the eye freed of its irritant. If this device 
fail, the aid of another person must be evoked. This person 
should station the patient in front of a window, and care- 
fully inspect the visible portions of the eye and conjunctiva. 
Should the foreign body be seen, unless it is imbedded in 
the cornea it may easily be removed by the dampened point 
of a handkerchief. Should it. still remain hidden, the helper 
should request the patient to look downwards, then, grasp- 
ing the margin of the upper lid with the thumb and fore- 
finger of the right hand, the lid should be pulled down- 
wards, while, with the. left hand, the upper margin of the 
cartilage of the lid, i.e.^ sl point about one-half inch above 
the eye-lashes, should be gently depressed with the blunt end 
of a pencil, while the margin of the lid is gently rolled back 
with the thumb and finger already engaging it. By forc- 
ing the patient to continue looking fixedly downward, a 
full view is had of the conjunctiva lining the upper lid and 
covering the globe, and a foreign substance may readily be 
removed in the manner just described. The eye may then 
be bathed in cold water containing boracic acid, if this pow- 
der be at hand, and in a few minutes the eye will recover its 
normal sensibility. 

If the foreign body is situated on the cornea and can- 
not be dislodged by gentle contact with the handkerchief, 
medical aid should be sought. The damage inflicted by 
well-intentioned but unskilled attempts at removal from 



WOUNDS AND INJURIES 235 

the cornea of foreign bodies which have become firmly im- 
bedded in the tough substance of that membrane is ex- 
tremely grave and every eye surgeon of experience has been 
compelled to remove eyes which have been lost by infection 
consequent upon the removal of such bodies by dirty tooth- 
picks, blades of knives, etc. Stringent measures should be 
adopted in all industrial establishments forbidding, in ear- 
nest terms, the attempts of fellow workmen and other so- 
called " handy men " to remove such bodies from the eye. 
Competent medical aid is alone capable of dealing with 
such cases. 

Nasal catarrh, in consequence of exposure to draughts 
and the inhalation of dust and other irritating substances, is 
common among workmen, and not infrequently disease of 
the lachrymal passages takes part in this inflammation of 
the mucous membrane of the nose. Once the protecting 
covering of epithelial cells of the cornea is broken, micro- 
organisms present in the diseased lachrymal sac gain en- 
trance into the tissues of the cornea, and, in a few hours, a 
purulent inflammation arises which usually leads to the 
total loss of the eye. The careful surgeon will discover the 
existence of such a complication and will take means to 
combat it, before pronouncing even a simple wound of the 
cornea to be free from danger. 

After the removal of foreign bodies, the eye should be 
carefully bandaged, to exclude irritants and to hasten the 
reformation of the epithelial covering. If inspection shows 
that the corneal tissue has been much damaged by the in- 
jury, ice compresses and the instillation of atropine are 
demanded. 

A painful and often troublesome injury results from 



236 HYGIENE OF THE EYE 

a scratch of the cornea by a finger-nail ( Fig. 76 ) , this acci- 
dent happening not infrequent^ to mothers by an unex- 
pected blow from a child's hand. Prolonged bandaging 
and the best of medical care is usually necessary before the 
healing of the torn cornea is attained. Women also suffer 
injury to the conjunctiva and cornea from burns by curl- 
ing irons. If at hand, a small quantity of white vaseline 
should be placed inside the lower lid, the eye bandaged, and 
medical assistance immediately obtained. 

The cornea is also frequently injured by scratches h?/ 




#' 

^^^ 



fe- . .d 

Fig. 76. — Erosion of cornea from finger-nail injury. 

twigs and branches of trees, and the author has seen sev- 
eral cases where severe injury was inflicted by the sharp 
points of a chestnut burr. 

The lodgement of caterpillar hairs within the eyelids 
may give rise to a very severe inflammation of conjunctiva 
and cornea, and may threaten the integrity of the globe. 

Injuries are sometimes confined to the lids. The author 
has, upon several occasions, seen the upper eyelid almost 
torn away by hooks of various kinds. The skin of the lids 
is frequently the seat of burns, and in the event of an ex- 
plosion, if the spontaneous closure of the lids has not been 



WOUNDS AND INJURIES 237 

quite quick enough to prevent, burning substances may 
gain access to the conjunctival sac and may injure the eye 
itself. 

Perhaps the most common type of chemical hums is 
that due to unslaked lime, the lime being splashed into the 
face of mortar-mixers and plasterers. When this occurs, 
the eye should be immediately flushed with an excess of 




Fig. 77. — Adhesion of the lid to the globe after lime burn. 

water and the patient hastened to an eye surgeon. At 
times, burns are occasioned by acids, when a similar course 
of treatment should be instituted. Ordinarily advice is 
given to counteract burns from alkalies, such as lye, am- 
monia, and lime, with weak acids like vinegar, and those 
from acids with weak alkalies like dilute soapsuds. These 
agents are not, however, always at hand, and water must be 
relied upon to rid the eye of the offending substance. 



238 HYGIENE OF THE EYE 

Burns are always of serious moment, often destroying 
the eye, although the immediate consequence of the accident 
seems trivial. Adhesions of the lid with the globe (Fig. 
77) , corneal opacification and ulceration, and actual shrink- 
ing of the globe itself are some of the sequelae which are 
observed after this class of injury. 

While surface wounds are often serious, injuries which 
cause a perforation of the globe (Fig. 78) are invariably 
so, not only on account of the damage done to structures 
vitally concerned with the integrity of the eye as a visual 




jif^' 



Fig. 78. — Perforating wound of the cornea with prolapse of the iris. 

organ, but also on account of the additional danger which 
they occasion of the eye being lost from sepsis, in conse- 
quence of the introduction of infective material. 

The simplest form of perforating injury is one which 
penetrates the cornea, but does not involve other ocular 
structures. The prognosis for sight and uncomplicated 
healing depends naturally upon the character and extent of 
the injury. A clear-cut wound, inflicted, for example, by 
a keen blade of a small knife, may heal rapidly, and inter- 
fere but slightly with vision, though the usually attendant 



WOUNDS AND INJURIES 239 

adhesion of the iris to the cornea, which occurs when the iris 
is permitted to come into contact w4th that membrane, in 
consequence of the escape of the aqueous humor, may neces- 
sitate operative measures later. Jagged tears of the cornea 
may, on the other hand, despite the healing process which 
is often accomplished by the surgical covering of the wound 
by transplanted flaps of conjunctival tissue, leave the eye 
totally blind, though the sublying structures may have 
escaped injury. 




-J 

Fig. 79. — The deadly scissors and the innocent victim. 

When an eye is injured by hat pins, pen-knives, blades 
of scissors ( Fig. 79 ) , and the dozen or more articles and 
implements in common use, not only is the cornea per- 
forated, but the lens and iris usually suffer as well. Even 
without treatment, providing the object inflicting the in- 
jury has been clean, in rare cases, the wound of entrance 
may close after a time, and the eye recover with more or 
less impaired vision. Usually, however, unless prompt 
treatment is instituted, the eye is lost from infection or 
subsequent shrinking. 

At times the iris escapes in perforating injuries, and 
the lens alone is involved. The capsule of the lens being 
broken, the aqueous humor enters the lens substance and 



240 HYGIENE OF THE EYE 

causes a general opacification of that structure, preventing 
the entrance of rays of L'ght into the eye. After a time, 
however, a diminution in the volume of the lens will be 
noted, and a gradual disappearar^ce of the opaque lens 
matter takes place by absorption. Necessarily, good vision 
can then only be obtained by the superposition of a strong 
convex spherical lens before the eye, to replace the crys- 
talline lens which has been lost, a correction which is rarely 
tolerated in comfortable binocular vision. 

Wounds which penetrate into the vitreous and are of 
large extent are usually attended with more or less loss of 
that structure and collapse of the globe. Injuries which 
involve the ciliary body are always regarded with grave 
concern by the surgeon, as experience has shown that this 
class of injuries is particularly liable to be followed by 
sympathetic involvement of the fellow eye. 

A person may suffer injury to an arm or leg and no 
inflammation be excited in the fellow member, no matter 
how severe the wound in the injured part, but if an eye is 
injured or inflamed, especially if, as has just been cited, 
the ciliary body is involved, there is always the possibility 
of a sympathetic inflammation occurring in the fellow eye. 
This peculiar characteristic has long been recognized, and 
it is for this reason that surgeons urge early removal of 
eyes which are at all likely to give rise to this trouble ; for 
once the inflammation has been transferred, though but in 
the slightest degree, no treatment or operation can stay its 
progress, and the sympathizing as well as the injured eye 
is usually lost. One of the saddest experiences of the eye 
surgeon is an unsuccessful pleading with an ignorant or 
stubborn patient to permit the removal of a worthless and 
dangerous eye, a procedure which would remove all menace 



WOUNDS AND INJURIES 241 

from its fellow, and to hear the demand for help which 
comes later, after the good eye has become involved and 
no surgical intervention or treatment is of avail. 

It would seem almost at times that the decision of 
whether an operation shall or shall not be performed should 
not be left with the patients and their friends, who are, as 
a rule, in no position to arrive at a sane judgment in the 
matter, but should be referred to some kind of a medical 
court. Apart from the needless suffering entailed by this 
self-inflicted blindness, the subject is of importance from 
an economic standpoint, as most of these individuals are 
incapable of supporting themselves and become cares upon 
the State. 

Gun-shot Wounds of the Eye. — In the autumn, 
during the open season for shooting game, gun-shot wounds 
of the eye are not infrequent. These are usually occasioned 
by small shot, and the wounds inflicted vary in proportion 
to the number of shot entering the eye and the parts af- 
fected. As a rule, wounds of this character are extremely 
serious, and often cause the loss of the eye. Shot lodged 
within the eyeball are readily located by the X-ray, but 
being non-magnetizable, their removal is attended with 
great difficulty and often leads to the loss of the eye. If 
the globe has been perforated and the shot lodge without 
the eye, useful vision may be saved provided no part of the 
eye vital to sight has been injured. Wounds with balls of 
large calibre are usually fatal to sight and generally de- 
mand the immediate removal of the eye. A not infrequent 
loss of sight from pistol wounds are those self-inflicted by 
would-be suicides, who, holding the barrel of the pistol to 
the temple in the expectation of blowing out their brains, 

16 



242 HYGIENE OF THE EYE 

advance the weapon too far forwards, and injure instead 
one or both optic nerves just before they enter the eyes. 

Another not uncommon source of injury is from a bullet 
or stone hurled against the eye fro|m a sling-shot. In cases 
such as these the globe is frequently not perforated, the 
injury resulting from the blunt force with which the missile 
strikes the eye. Rents in the iris and choroid, dislocation 
of the lens, and detachment of the retina are the usual 
sequelae. 

It is beyond the scope of this work to describe the fre- 
quent and extensive injuries inflicted upon the eyes in war. 
They vary from the complete blowing out of the eyes to 
every conceivable form of eye injury, the amount of dam- 
age done depending upon the nature and form of the pro- 
jectile and the part of the eye injured. 

Injuries from Balls. — These may be inflicted by balls 
of all kinds, i.e., cricket, base-ball, golf, tennis, racquet balls, 
etc., and, generally speaking, the smaller the ball the greater 
the danger to the eye. When a cricket or base-ball strikes 
the eye, it often happens that the rim of the orbit, the bony 
receptacle in which the eyeball lodges, receives the force 
of the blow and the eyeball itself escapes. Unfortunately, 
however, the consequences to vision may be very serious, for 
it not infrequently happens that the force of the blow is 
great enough to produce a fracture in one of the walls of 
the orbit and the extension of the fracture to the apex of the 
orbit causes a severance of the fibres of the optic nerve, as 
that structure passes through the optic foramen, as it 
emerges from the cranial cavity into the orbit. The prog- 
nosis, therefore, in cases of sudden blindness following such 
injuries, is hopeless. When, however, an interval of time 
elapses before the loss in vision becomes manifest, there is 



WOUNDS AND INJURIES 243 

some chance that sight may be regained, as in the latter case 
the blindness may have been caused by a hemorrhage into 
the sheath of the nerve, which is capable of subsequent 
absorption. The author remembers a case of a young 
father who, while romping with his little son, received a 
violent blow over the eye from his child's head. There was 
no loss of vision until some hours later and fully a day 
elapsed before the eye on the injured side became totally 
blind. After several days of blindness, full visual acuity 
was gradually regained. 




Fig. 80. — Rupture of the eyeball. 

The circumference of the orbital aperture is too great, 
however, to protect the eye from injury by small balls, and 
most eyes struck squarely by racquet and golf balls are 
hopelessly lost, the envelope of the eye being split (Fig. 
80) and the contents of the eye extruded as a result of the 
accident. If the blow has been a glancing one, the injury 
may not be so serious, and the globe, partially flattened 
for the moment by the blow, may escape without injury to 
the cornea and sclera. Ordinarily, however, in such cases, 
the iris or choroid is torn, the lens dislocated, and, what is 



244 HYGIENE OF THE EYE 

usually of more serious moment, the retina detached 
(Fig. 81). 

In addition to participating in the class of injuries just 
mentioned, golf halls may menaces^ the integrity of the eye 
in quite another manner. During the past few years a 
number of cases have been reported where severe burns 
of the eye have been occasioned by boys and others, mostly 
caddies and professional golfers, cutting into the balls to 
ascertain their contents (Fig. 82) . Consequent thereto an 
explosion of extreme violence occurs, the semifluid mass 




Fig. 81. — Blood in anterior chamber following blow upon the eye. 

contained in the core of the ball being expelled in all direc- 
tions. Several eyes have been totally lost in this way and 
others severely injured. Fortunately, this unhappy experi- 
ence does not follow the incision of all golf balls, but ap- 
pears to be limited to two kinds of balls, which were in 
common use for a time on account of their lightness. It 
would appear from an analysis which was made of the con- 
tents of several of the balls after the explosions had oc- 
curred, that the core consisted of a mixture of barium sul- 
phate and a free alkali. In balls of another make, the core 



WOUNDS AND INJURIES 



245 



seemed to be made up of zinc chloride. Owing to the 
initiative of the Pennsylvania Commission for the Conser- 
vation of Vision, the United States Golf Association caused 
placards to be displayed in all the club houses of the asso- 
ciation, warning of the danger of cutting into golf balls. 
The Massachusetts Legislature also passed a bill prohibit- 
ing the sale of balls which contained any caustic fluid. 




Fig. 82. — Cutting into a golf ball. The ball, at the centre, contains an acid which explodes 
when exposed to the air. A great many cases of loss of sight have been reported as a result of 
curiosity of the contents of golf balls. 

While the two makes of dangerous balls have been 
largely withdrawn from the market, it is not unlikely that 
some of the balls may still be in circulation, so that the 
caution recommended by the golf association should still 
be given publicity, and caddies and others warned under no 
circumstances to investigate the contents of golf balls of 
any description. 

Snoav Blfndness. — The dazzling reflection of the sun's 



246 HYGIENE OF THE EYE 

rays from snow and ice fields is often a source of great 
annoyance and danger to mountaineers and arctic ex- 
plorers. Unless properly protected by some form of 
colored or smoked glass, the excessive amount of ultra- 
violet rays burns the conjunctiva or even the cornea, and 
may cause serious inflammation. For protection against 
snow blindness in arctic, antarctic, and mountaineering ex- 
peditions, the best frame is the common open spectacle 
frame, fitted with large mussel-shaped smoked or tinted 
glasses. Glasses tinted yellow-gl-een entirely absorb the 
ultra-violet rays and the colors of the landscape, seen 
through them, are not much modified. All more or less her- 
metical arrangements of goggles for the exclusion of side 
lights have been found by travellers to be superfluous and 
serve only to moisten the glasses. 

Lightning stroke has been followed by cataract and 
various other changes in the interior of the eye. The author 
observed a case of diffuse oedema of the retina with total 
loss of sight follow this accident. Full vision was ulti- 
mately obtained in each eye. 

Industrial Injuries to the Eyes^ 

Statistics show that in the United States 75,000 per- 
sons are killed annually through accidents. Of this num- 
ber, 35,000 die from industrial injuries. Of 2,000,000 
annual non-fatal accidents, probably 160,000 are accidents 
to the eyes. 

^ Contents of this section based on a paper by the author 
before the Department of Industrial Welfare and Efficiency, 
Bureau of Commerce and Labor of the State of Pennsylvania, at 
annual meeting, November 23, 1916, fromi material furnished by 
the National Committee for the Prevention of Blindness. 



WOUNDS AND INJURIES 247 

Although the last census records the number as smaller, 
there is strong evidence to place the number of blind in our 
country at about 100,000, of whom approximately 10,000 
lost their sight as the result of accidental injury in in- 
dustrial occupations. Quite apart from the suffering and 
unhappiness entailed by these accidents, which cannot be 
appraised in dollars and cents, it has been estimated that it 
will cost the nation nearly ten million dollars to care for 
these blinded workmen during the remainder of their lives. 

According to a statement recently issued by the 
National Association for the Prevention of Blindness, the 
industries providing the greatest number of industrial ac- 
cidents to eyes are foundries, galvanizing plants, machine 
factories, metal and wood working plants, lead and color 
factories, chemical works, and the dusty and poisonous 
trades. The classes of workmen showing the largest per- 
centage of eye accidents are smelters and furnacemen, 
welders, grinders, and machinists, furnace helpers, and 
railroad workers. It may appear rather strange that this 
last class, railroad men, are so subject to eye accidents in 
their work, yet the records of the great railway systems 
which operate one-half of the total mileage in the United 
States, admit for the period 1908-1910 seven cases of total 
disability, i.e., loss of both eyes, while three hundred and 
ninety suffered the loss of one eye. Railroad employees ex- 
posed to eye injuries preventable by goggles are chippers, 
riveters, boilermakers and grinders. 

One of the greatest menaces to the eye is burns from 
molten metal. This may occur in filling the ladle with the 
metal while it is still in a liquid state, or when the latter is 
being poured into the mould, the sparks flying in all direc- 
tions, frequently burning the face and eyes of the work- 



248 HYGIENE OF THE EYE 

men. Most serious are the explosions which follow when 
molten slag or lead are permitted to come in contact with 
vessels or implements containing moisture, the superheated 
steam thus generated blowing the hot metal with great 
force for considerable distances (Figs. 83, 84, and 85). 
At times considerable masses of molten metal may force 
their way between the lids and the globe, and, owing to the 




Fig. 83. — Man with eyesight destroyed and face badly disfigured by burns from molten metal. 

physical phenomena of calefection, whereby the tissues are 
separated from the metal by the sudden evaporation of the 
fluid on the surface of the eye, a perfect mould of the con- 
junctival cul-de-sac is formed, comparatively but little 
damage being done to the contiguous structures. At other 
times, however, the injurious effects of such explosions is 
very great, and the author remembers to have seen a case 
in the practice of a colleague where a large fragment from 



WOUNDS AND INJURIES 



S49 




Fig. 84. — In this case the babbitt metal completely covered one eye and if employee had 
not been protected by this safety precaution, he would undoubtedly have lost both eyes, in- 
stead of receiving but a slight burn about the face. 




Fig. 85. — Glaaaea used by workmen pouring babbitt. 



250 



HYGIENE OF THE EYE 




Fig. 86. — A foundry chipping yard, eyes of workmen properly protected by goggles. 







p.. W-^^ '^m 




"■ -^-^ 


-;:■•■■■.«,. 





Fig. 87. — Glasses used by wprkmen chipping wheels; also burlap guard to catch flying chips of 

steel. 



WOUNDS AND INJURIES 



251 



a red-hot chisel forging completely destroyed the eye of a 
bystander. 

Of all the various workmen engaged in the industries, 
the most liable to ocular injury are chippers (Figs. 86 and 
and 87) . Chippers are men who remove the rough surface 
from steel castings which frequently remain after the molten 
metal has hardened, this being accomplished either by a 
hand chipper or by means of the more modern pneumatic 




Fig. 88. — Man with hood of brass wire, standing before furnace. 

implement. The fragments dislodged fly from the casting 
with great velocity and force, and frequently injure not 
only the eyes of the chippers themselves, but those of their 
fellow-workmen or the passerby. Goggles are imperative 
for all those engaged in chipping or in the vicinity, and 
screens composed of wire or burlap should be so placed that 
they act as buffers to the flying particles. Flying scale is 
frequently thrown off from the rolls of a blooming mill and 



252 



HYGIENE OF THE EYE 



employees engaged in this work should wear protecting 
masks of fine brass netting (Fig. 88) . 

When water and steam is turned into a water-gauge^ 
with which all boilers are provided, the pressure at times 
is great enough to burst the glass and to blow the fragments 




Fig. 89. — Water gauge glass on boilers, protected with brass casting, having a small slit 
in the front and back. The gauge of water can be viewed from the ground. There is an incan- 
descent light placed at back of glass to reflect the stage of water. 

into the face of the engineer observing the gauge. In a 
recent year in Massachusetts seven men lost the sight of 
both eyes and one workman that of one eye from the burst- 
ing of such gauges ( Fig. 89 ) . This has been obviated by 
providing the glass column with a protecting shield of 
brass which covers the glass when turning steam and water 



WOUNDS AND INJURIES 



253 



into the gauge and is capable of being rotated to the side 
when the danger of this act is over and it is necessary to 
ascertain the registration of the water in the boiler. The 
Xew York Central roads have installed an admirable model 
of this device in their works, and no accidents to the eyes 
have occurred from bursting gauges among their many 
employees since it has been in use. 




Pig. 90. — Glasses used by operator at emery wheel; also notice warning for men to wear glasses. 

The emery wheel is a constant source of danger. When 
operated at high speed, it may burst and its fragments kill 
or injure workmen close at hand. Most serious are the 
burns and scars inflicted upon the cornea of those who work 
with unprotected eyes, by the dust given off from the wheel 
while tools and instruments are being ground upon it. The 
breaking off of fragments from the tools in the process of 



254 HYGIENE OF THE EYE 

grinding provides, however, a still greater source of dan- 
ger to the eyes, and many an eye has been blinded by these 
flying particles of steel (Fig. 90). Many manufacturing 
establishments now protect their workmen from injury 
from bursting wheels by encasing them in hoods of steel, 
and the eyes of the men from broken particles of wheel 




Fig. 91. — Hammer — showing chip. 

and from flying chips by shields made of heavy plate glass,^ 
the transparency of the glass permitting the workman to 
observe the tool he is grinding. Most wheels are also pro- 
vided with exhaust connections from the rear of each hood 
to a forced draft pipe, which carries away much of the dust 
by a vacuum system. 

Another frequent source of danger to the eyes, not only 



WOUNDS AND IXJUMES 255 

in the industries but also in domestic life, is the breaking 
of steel particles from the head of tools which have become 
flattened over or '' mushroomed '' from long use (Fig. 91 ) . 



DANGER 

YOU ARE WARNED 

AGAINST WORKING 

WITHOUT PROPER 

EYE PROTECTORS OR 

WITH BATTERED TOOLS 

GET PROPER TOOLS 

AND EYE SHIELDS 

FROM YOUR FOREMAN. 



Fig. 92. — Warning placard posted in the workyards of the Tennessee Coal, Iron and 

Railroad Company. 

While mushrooming is especially liable to happen to cheap 
tools, it may occur also in the best hand-wrought imple- 
ments, for a hammering tool must be fairly soft to prevent 



256 HYGIENE OF THE EYE 

its becoming brittle, and if used too long it will naturally 
flatten out. The prevention of accidents from this source 
consists in sending the tools to the blacksmith just as soon 
as they begin to show signs of wear. The Tennessee Coal, 
Iron, and Railroad Company has considered this danger 
of sufficient importance to cause a warning placard to be 
posted in their workyards (Fig. 92). 

Some of the most serious and ofttimes hopeless cases 
the ophthalmologist is called upon to treat occur from Mast- 
ing operations^ either in mining or in excavating for founda- 
tions, etc. Such accidents result either from the premature 
explosion of cartridges with too short fuses, or by delayed 
explosions, the injuries occurring when the workmen, after 
what they suppose sufficient time has elapsed after the 
charge has been fired, seek to investigate the failure of the 
explosion. At other times, when a number of cartridges 
have been fired by an electric current, the workmen clear- 
ing away the debris caused by the explosion are seriously 
injured by the delayed explosions of several of the cart- 
ridges which had failed to go off at the initial charge. The 
injuries to the eyes in such cases are frequently caused by 
little bits of copper from the exploded caps of dynamite or 
from fragments of rock, substances incapable of magnetic 
attraction, and on that account extremely difficult and often 
impossible to remove from the eyes. 

Another source of injury to the eyes is from exposure 
to an excessive amount of heat and light rays, emanating 
from furnaces in which glass and metal are being subjected 
to a temperature of great magnitude. In welding of metals 
by the electric arc, the oxygen-hydrogen flames or some 
similar high temperature medium, a temperature of from 
4000° up to as high as 7500° F. is frequently attained 



WOUNDS AND INJURIES 257 

( Fig. 93 ) . The ultra-violet rays generated by this process 
are extremely harmful to the eyes, inducing changes which 
may lead to blindness. In some of the processes it is neces- 
sary for the workmen in charge to gaze intently into the 
furnace and watch for the change in color of the molten 
mass which indicates that the desired transformation in its 
composition has been attained. Workmen subjected to 
such intensity of light and heat radiations must wear proper 




Fig. 93. — Mask used by operator to protect eyes and face while using electric welding 
machine, the rays from which are very destructive. 

protecting devices, and welders are usually equipped with 
a complete metal helmet, which is absolutely light-proof, 
except for the ocular apertures, which are covered with 
certain forms of colored glasses. Mention will be made 
later of the best kind of glass for this purpose (Fig. 94) . 

Faultily constructed electiical appliances may be a 
source of eye injury, blindness from cataractous forma- 
tions in the lens sometimes occurring in eyes subjected to 
the blaze of light from a short circuit. The author had 

17 



258 



HYGIENE OF THE EYE 



under his care a few years ago a workman in one of the 
large coal companies of the State who had lost his sight 
in this way, but who fortunately regained it after a success- 
ful cataract operation (Fig. 95) . Venturesome electricians 
occasionally essay to light a cigarette from an electric arc, 
ofttimes with disastrous consequences. To avoid acci- 




FiQ. 94. — Glasses used by open hearth employees to protect eyes while looking in open hearth 

furnaces. 

dents from electric flash, all switches, fuse-boxes, etc., 
should be enclosed. 

Bottlers of aerated waters and those engaged in their 
distribution, such as bar-tenders and soda fountain attend- 
ants, may suffer injury to the eyes by flying corks or by 
fragments of glass from the bursting of a bottle. This 
latter accident may be guarded against in machine bottling 
in factories by properly placed wooden screens. 



WOUNDS AND mjURIES 259 

As has been aptly put by GiiFord ^: " The largest con- 
tingent of the industrial army is made up of agricultural 
laborers, and in all but the large manufacturing centres 
the majority of serious eye accidents occurs in this class. 
As might be expected from the varied activities of the man 
on a farm, the character of these accidents shows the great- 
est diversity. These include quite a number of wounds 
from flying steel occurring while the victims are hammer- 
ing at their farm machinery. A lot of wire-fence injuries 
result from running into or from being thrown into the 

r 




Fig. 95. — Electric cataract. 



barbs, or perhaps more often from staples flying back when 
the wires are being taken ofl" of fence posts. A coil of 
tempered wire is a very treacherous thing. The ends have 
a way of springing about in an entirely incalculable man- 
ner, a fact which every one handling wire should keep in 
mind. Then come the botanical injuries, of which the 
typical ones are superficial, but ragged wounds of the cornea 

^ " Industrial and Household Accidents to the Eye," Harold 
Gifford, M.D. Conservation of Vision Series, Pamphlet II, Amer- 
ican Medical Association, Chicago. 



260 HYGIENE OF THE EYE 

from blades of corn or beards of wheat, and the more deadly 
penetration by thorns and weed stubs, which more com- 
monly occur to children. Wood-chopping injuries are also 
typical and common; the dangei- to the bystanding child 
being greater than to the man who wields the ax. Horse 
and mule kicks furnish a considerable number of the eye 
injuries on the farm, and this is one of the rare forms of 
standard eye injury which would generally not be pre- 
vented by the use of spectacles. Kicks from cattle rarely 
injure the eye, on account of the limited vertical displace- 
ment of the animals' hoofs. 

" A fairly numerous list of eye accidents belong to what 
may be termed household injuries. An enumeration of 
some of the most typical of these may do some service in 
the way of prevention. Chips of steel are not infrequently 
driven into the eye through the attempt of some house- 
holder to open a box by driving a hatchet under the lid with 
a hammer. This combination of hammer and hatchet is 
particularly deadly, because, on account of the relatively 
large mass of the pieces of metal employed, the chips which 
are broken off the edges fly with great velocity. This dan- 
ger should be kept in mind, and if it seems necessary to 
drive a hatchet or ax into a crack, the danger can be averted 
by interposing a piece of wood between the two surfaces of 
metal, or by using a heavy stick of wood instead of a 
hammer. The attempt to drive a nail into a hard plank, on 
the part of a novice, not infrequently results in the nail 
flying back so as to injure the eye. Many an eye is lost 
by the chopper of kindling-wood, one end of the stick 
struck at right angles being frequently thrown up with 
great violence. Striking the eye against some projecting 
corner of furniture while the victim is going about in the 



WOUNDS AND INJURIES 261 

dark is a common cause of household eye injury. This 
is most apt to occur through the patient's stooping over in 
the dark and bumping his eye on a projecting chair-post. 
These injuries frequently cause entire loss of sight. Every 
one going about in the dark should hold the hands six inches 
or so in front of the eyes. These injuries are also a warn- 
ing to eliminate sharp corners on tables, as these are of just 
the right height to put out the eyes of the active child. 

" Accidents with household chemicals are not uncom- 
mon ; a bottle of ammonia, or some strong acid, or a can of 
concentrated lye being spilled into the eyes while being 
lifted down from some shelf. Even when chemicals are put 
away tightly corked the cork frequently goes to pieces 
under their influence, so that after being set away for 
some time, some of the contents easily escapes when the 
bottle is slightly tilted. This should lead to the enforce- 
ment of a rule requiring all such chemicals to be put on a 
high shelf, far back out of the reach of little children." 

Methyl or Wood Alcohol Poisoning. — About 30 
years ago, under the names of Purified Wood Alcohol, 
Columbian Spirits, Colonial Spirits, etc., there was intro- 
duced a dangerous product of the destructive distillation of 
vegetable fibre, as a cheap and harmless substitute for ordi- 
nary methyl or wood alcohol. Unfortunately, however, 
the claim of harmlessness was not long maintained, for 
cases of sudden death as well as of total and incurable 
blindness began to multiply following the adulteration of 
various popular medicaments with it. A careful investiga- 
tion made by several prominent oculists about ten years 
ago^ discovered 275 instances of death or blindness (some- 

"^ Buller, F., and Wood, C. A. : " Poisoning by Wood Alcohol." 
The Journal of the American Medical Association, Oct. 1-29, 
1904, pp. 972, 1058, 1117, 1213 and 1289. 



262 



HYGIENE OF THE EYE 



times both) directly traceable to drinking or inhaling the 
fumes of Columbian spirits or some other form of " de- 
odorized " wood alcohol, such as occur in the adulterated 
manufacture of Jamaica ginger, essence of lemon, cheap 
whiske}^, etc. In addition to the visual symptoms, there 
is usually acute abdominal pain, nausea, and vomiting, with 
symptoms of cardiac depression. 

Poisoning may also occur from inhalation of the fumes 
of wood alcohol. This generally happens when the exhala- 




FiG. 96. — Three bottles containing wood alcohol sold by druggists in New York City. 

tions are mixed with rebreathed air, as in varnishing the 
interior of beer vats, closets, etc. Susceptible subjects may 
at times suffer from a single rub with alcohol containing 
the deodorized mixture. Manufacturers of wood alcohol 
should be compelled by law to so label their products that 
even the most ignorant should learn of its poisonous char- 
acter, but better still, its use should be prohibited (Fig. 96) . 
So great is the danger to life and sight from wood 
alcohol, that it would seem only sane to prevent its manu- 
facture by law, especially as we now have "denatured alco- 



WOUNDS AND INJURIES 263 

hoi," a grain or ethyl alcohol which by its cheapness 
removes any excuse for the use of the poisonous methyl 
alcohol. The admixture of various ingredients to de- 
natured alcohol renders it unfit for drinking purposes, but 
does not destroy its value for domestic consumption or for 
the purposes of commerce. 

Lead Poisoning. — On account of the diversified use 
of this metal, poisoning from it is not uncommon. Per- 
haps house painters working with lead paint suffer more 
frequently than others, but printers handling type are af- 
fected by it, as well as employees in lead factories of vari- 
ous kinds. Hair dyes containing lead may evoke symp- 
toms, and seamstresses, from biting off thread which has 
been weighted with sugar of lead, may also be aifected. 
Children have been known to develop lead poisoning by 
sucking their fingers after handling fragments of wood 
upon which the paint which formerly covered it had be- 
come disintegrated by exposure to the weather. Ordi- 
narily lead colic and other symptoms of poisoning by the 
drug precede those of sight, but loss of vision leading in 
some cases to total blindness may be the first sign. Gen- 
erally prompt and efficient treatment will accomplish a 
cure. 

Illumination of Workshops. — An indirect, though 
probably a not infrequent cause of accidents in our fac- 
tories, is improper lighting of the workrooms. In many 
establishments the lighting is so insufficient or the lighting 
fixtures so badly placed, that workmen are either unable to 
see the dangers which beset them, or their eyes, weakened 
by the glare of unprotected lights, become incapable of 
properly fulfilling their functions. 

Dr. Nelson M. Black, of Milwaukee, who has made 



264 HYGIENE OF THE EYE 

an extensive study of factory illumination, says in this 
connection: "Factories should be well lighted, first be- 
cause poor lighting injures the eyes, and second because 
poor lighting detracts from the earning capacity of the 
workmen and is an extravagance. Good lighting is eco- 
nomical. Superior work can only be accomplished under 
good lighting conditions, with which vision is preserved, 
health is conserved, and factory output is increased from 
8 to 15 per cent. Accidents are much less likely to occur. 
The saving produced by good lighting will pay many times 
over the cost of the installation of good lighting facilities. 
The maximum number of accidents occur during the time 
in which artificial light is used. A well-lighted factory is 
more productive than a poorly lighted one. Bad lighting 
is detrimental to eyesight and health. It is an extrava- 
gance that factory owners can not afford." 

The illumination of all rooms should be uniform and as 
devoid of shadows as possible. Ordinarily the system of 
indirect lighting which has so many admirable features, is 
unadapted to this kind of illumination, as the ceiling and 
walls of factories are necessarily darkened by smoke and 
dirt and there is no reflection of the rays of light. Some 
steady and sufficient form of direct lighting is therefore 
indicated, and an overhead system which throws a diffuse 
light upon all the machines is preferable to one which has 
for its object the illumination of single lathes, wheels, etc. 

To prevent and minimize the danger of ocular injuries 
occurring in industrial occupations, several essentials must 
be emphasized. In the first place, it should be the duty of 
the employer to install in his workplace every form of 
safety device which is on the market and which is adapted 
to the peculiar form of his industry. Proper goggles should 



WOUNDS AND INJURIES 



265 



be furnished to the employees and a sincere and active cam- 
paign of instruction instituted in the works, to instruct and 
demonstrate to the workmen, the various dangers to which 
they are subjected, and explanation and reasons given for 
the safety devices which have been installed. An efficient 
first aid service should be created, and so far as the eyes are 
concerned, workmen should be absolutely prohibited from 
offering any aid whatsoever in case of injury. Too many 
eyes are lost in consequence of well-intentioned though mis- 




FiG. 97. — Steel chip in lens. 

directed attempts at removal of chips and cinders by 
" handy men " about the shop. The author is convinced 
from a long experience in treating workmen's eyes, that 
dirty toothpicks and ends of matches, rusty pocket knives, 
etc., are responsible for many hundreds of blind in his own 
State alone. 

In case of injury a protective bandage should be ap- 
plied and medical aid sought at once. In the proper clean- 
liness of the hospital, with its manifold appliances, the 
skilled physician will detect that the chip which the work- 
man had thought had only grazed his sight or had dropped 



HYGIENE OF THE EYE 



from the eye entirely after inflicting a slight wound, has 
in reality entered the globe (Fig. 97) . Under X-ray ex- 
posure, the chip is located, a magnet applied, the foreign 
body removed and the eye saved. / How different from the 




Fig. 98. — Patient in position before giant magnet. 

fate of an eye that has been scraped by a rusty knife by a 
comrade, allowed to become infected, and is lost in a few 
hours from suppuration (Figs. 98, 99, and 100). 

Placards graphically describing the dangers of injuries 



WOUNDS AND INJURIES 267 

to the eyes in the various occupations in which they are en- 
gaged, printed in the languages of the workmen, should be 
hung in prominent positions in the works. In addition to 
these sources of information, the foreman or others in 
authority should give explanatory and admonitory talks 
to the workmen at frequent intervals, and every effort 
should be made to acquaint them with the danger of their 
work. 

With the employer thus engaged at no little cost and 




Fig. 99. — Skiagraph showing foreign body in eye. 

annoyance to himself to safeguard his employee, it seems 
but just that the workman should wilHngly cooperate to 
the best of his abihty and avail himself of the safeguards 
which have been provided for him. Indeed, the exigencies 
of the situation seem so great, that it does not seem un- 
reasonable to attach some penalty in the event that proper 
treatment is refused or postponed. 

This would appear to be especially proper in the mat- 
ter of wearing goggles, for the usefulness and effectiveness 



268 



HYGIENE OF THE EYE 



of this simple device to protect eyesight has now been 
proven beyond gainsay. Thus the American Car & 
Foundry Company has proven that the use of goggles has 




Fig. 100.— Taking X-ray for supposed foreign body in eye. Head of patient in X-ray machine. 

reduced accidents in their plant seventy-five per cent. It 
is argued by some that the wearing of goggles in the event 
of accident only jeopardizes sight the more, on account of 



WOUNDS AND INJURIES 269 

the liability of injury to the eyes from the broken glass of 
the goggles. As a matter of fact, however, this apparent 
danger is without foundation, as may be judged by the 
following evidence. There has not been a single case of 
injury to the eyes from broken glass since goggles were 
introduced into the shops of the New York Central Rail- 
road. The American Steel Foundries Company collected 
94 pairs of goggles, all with lenses broken from flying chips 
of steel from their works during a period of 3 months, and 
in every case the eyes had escaped injury. Had the goggles 
not been worn, some of the eyes at least would have been 
lost. In another large steel foundry where spectacles have 
been worn since 1911, 48 pairs of goggles were collected in 
one month with lenses broken by flying pieces of steel ; 297 
pairs were gathered among the several foundries covering 
a period of six months. During this entire period not one 
serious eye accident occurred.^ 

Furthermore, in an experience of nearly 25 years, dur- 
ing which the author has treated many hundreds of eyes 
injured in industrial establishments, chiefly in his service 
at the Wills Eye and Howard Hospitals, of Philadelphia, 
he does not remember to have seen a single eye injury from 
a broken goggle, nor can he recollect having observed 
similar accidents in the practice of any of his colleagues. 
Manufacturers of goggles are exceedingly careful to obtain 
a proper tensile strength of glass and frame. The author 
is informed, for example, that one of the tests applied con- 
sists in dropping a hardened steel ball five-eighths of an 
inch in diameter, 20 inches from an electric magnet directly 



* This information was derived from a statement submitted 
to the author by the National Association for the Prevention of 
BHndness. 



270 HYGIENE OF THE EYE 

upon the surface of the lens, without permitting the latter 
to rest on any support other than its own frame. The 
lenses subjected to this test will withstand 85 blows of this 
kind without breaking, and the construction of the frame 
is such that in the event of a breakage occurring, the 
frames tend to push the broken glass away from the eyes 
instead of allowing it to be pressed in. 

The perfect goggle has not yet been made. It is true 
that there are a large number of quite satisfactory goggles 
on the market, which serve the purpose admirably of pro- 
tection against such accidents as are caused by flying frag- 
ments of steel, etc., for all that is necessary under such 
conditions is a glass of sufficient strength to resist the im- 
pact of the foreign body, and wire or leather-screened sides 
with small apertures provided permitting of some cir- 
culation of air, to prevent the entrance of chips from the 
side. To save the eyes from injury from chemical acci- 
dents and those from molten metals, greater protection is 
necessary, and some form of transparent medium other 
than glass which will not become fogged or steamed when 
subjected to heat and gaseous fumes. 

A special form of goggle is necessary when the eyes are 
exposed to the action of intense heat and light rays, such 
as occurs in oxy-acetylene welding, etc., on account of the 
injurious eff*ect not only of the heat, but also of the 
ultra-violet rays generated in such processes upon the eyes. 
This has been accomplished in the past by the use of glasses 
that absorbed the infra-red or heat radiations. The objec- 
tions to this method are — first, that it has been found im- 
possible to make a glass that would absorb sufficient of the 
dangerous infra-red or heat radiations at one end of the 
spectrum and the ultra-violet or chemical rays at the other 



WOUNDS AND INJURIES ^271 

without cutting down the useful and harmless visible light 
to such an extent that it was extremely difficult for the 
workman to see his work ; second, that the glass by absorb- 
ing heat radiations soon becomes intensely hot and then 
gives out heat radiations itself, thus defeating the object in 
view. 

Quite recently, Professor Pfund, of Johns Hopkins 
University, conceiving the idea of getting rid of the infra- 
red or heat radiations by reflection, devised the lens which 
bears his name and which is made as follows : A flat piece 
of Sir William Crookes, or other glass of like nature, is 
coated with an almost infinitely thin layer of 22 karat gold. 
This gold layer being extremely delicate is protected by a 
flat piece of hard white crown glass. According to Pro- 
fessor Pfund, the action of the combination is as follows: 
all of the radiations, except the extreme ultra-violet, pass 
freely through the hard white crown glass. Encountering 
the gold layer, the ultra-violet and visible radiations up to 
about the middle of the red, pass without difficulty between 
the little particles composing the gold atoms. At about the 
middle of the red the light waves become too long to pass 
between these little particles and rebound or are reflected. 
Thus half of the red and practically all the infra-red or 
heat radiations or waves are reflected or thrown back. The 
ultra-violet and visible radiations or waves which have 
passed through the gold layer encounter the Sir William 
Crookes glass, which allows the visible light to pass freely 
but absorbs the ultra-violet. Thus we have disposed of the 
infra-red or heat waves by absorption, and have passed the 
visible. This visible light can be regulated by varying the 
thickness of the gold coating. As regularly made the coat- 
ing is of such thickness as to pass 25 per cent, of the visible, 



272 HYGIENE OF THE EYE 

but, if necessary, can be made to pass 75 per cent, of the 
visible without seriously cutting down the efficiency in the 
infra-red or heat end of the spectrum. As regularly made 
it refracts 98 per cent, of the heat and is claimed by Pro- 
fessor Pfund to be at least twenty times as efficient as the 
best of the old style protecting glasses for the same trans- 
mission in the visible spectrum. Proof of the practical 
value of Professor Pfund's glasses still awaits, the author 
believes, practical demonstration. 

According to Dr. Nelson M. Black, of Milwaukee, 
who has long been interested in this subject: "Glass in 
which the color tends toward a yellow or yellowish green 
affords the greatest protection from harmful rays. Such 
glass is found on the market under the name of amber, 
euphos, fieuzal, akapos and noviol glass. Even this glass 
must have added to it, in the process of manufacture, a 
dark smoked tint to reduce the intensity of the glare in 
order that it may be used with comfort. 

" Deep red glass is an effective protection against dan- 
gerous light and is in general use in many industries. It is 
usually combined with yellow, blue, or green and blue 
glass. The objection to such a combination is the inability 
to distinguish details and to see to get about, also the in- 
creased weight caused by using two or more pieces of glass." 



CHAPTER XVII 

EFFECT OF CERTAIN BEVERAGES AND DRUGS 

The eye is susceptible to the action of a number of poi- 
sons, which have been considered elsewhere, but there are 
other substances not usually considered to be poisonous 
which are in common use as stimulants and which may at 
times exercise a most deleterious influence upon the eyes. 
These are tobacco and alcohol. 

Tobacco. — That not all users of tobacco suffer from 
their eyes is apparent, as the use of tobacco is widespread 
and ocular complications from the habit are but rarely 
met with. Yet the experience of every eye surgeon is full 
of instances where the abuse of tobacco has seriously im- 
paired sight. For this unfortunate occurrence several con- 
tingencies are necessary. First, adult life; secondly, the 
absorption into the system of a large quantity of nicotine, 
either by smoking or chewing or taking snuff to excess, 
or by the prolonged handling of tobacco by workers in the 
weed. A third factor of disturbed digestion, usually as an 
indirect consequence of tobacco abuse and not infrequently 
of an associated too free use of alcohol, is also not infre- 
quently present. 

The quantity of nicotine necessary for absorption be- 
fore tobacco blindness or tobacco amblyopia, as it is called, 
manifests itself, varies very greatly in different individuals. 
Many escape who must be saturated with the poison, show- 
ing that the degree of tolerance of tobacco varies in dif- 
ferent individuals. Undoubtedly, as has just been sug- 
gested, the state of the general health has much to do in 

18 273 



274 HYGIENE OF THE EYE 

maintaining this tolerance, large quantities of cigars being 
consumed without provoking any symptoms, until a shock 
or prolonged mental strain or other derangement of the 
vital processes occurs, when thd visual disability at once 
manifests itself. 

The symptom first noted is usually an increasing diffi- 
culty in reading. Soon not only the type appears blurred, 
but distant objects as well appear fogged, the cloud being 
always densest between the eyes and the object regarded. 
The recognition of color is affected and those engaged in 
occupations in which the recognition of color is requisite, 
such as railroad men and pilots, are no longer able to dis- 
criminate between red and green. Undoubtedly a number 
of marine and railroad accidents have been caused by this 
interference with the color sense, the affection coming on 
so insidiously that the mariner or engineer who has previ- 
ously had no difficulty in recognizing signals and has suc- 
cessfully passed color blind tests has no suspicion that his 
ability to discriminate between the colors of the signals has 
been impaired. 

Most poisons have a selective tendency in their effect 
upon the structures of the body, and nicotine, in pursuance 
with this general rule, damages those fibres of the optic 
nerve which are connected with the macula lutea in the 
retina, which will be remembered to be the seat of direct 
and most acute vision, other portions of the nerve and 
retina escaping. If the abuse of tobacco is persisted in, 
total atrophy of these fibres follows and useful vision is 
lost. 

The prevention of tobacco blindness lies either in totally 
abstaining from the use of tobacco or in moderation. There 
are those, and perhaps this is true of the majority, who 



EFFECT OF CERTAIN BEVERAGES AND DRUGS 275 

would be far better off physically if they did not use 
tobacco in any form. Few gain the pleasure and solace 
from its use which they crave and expect, and no one can 
truthfully assert that tobacco is in any way a help to 
health. The custom of using tobacco, however, is so wide- 
spread that it is unlikely that hygienists will make much 
headway in their efforts at its control by preaching absten- 
tion and must be satisfied with the half-way measure of 
moderation. But as so often happens, what is moderation 
for one is abuse for another, so that any attempt at fixing a 
definite amount of tobacco safe for daily consumption 
would be futile. Under ordinary circumstances, however, 
it would appear that smoking three or four moderately 
strong cigars each day should suffice as a maximum, and if 
this rule be adhered to it is unlikely that any trouble with 
vision will result. So much is certain, that once the symp- 
toms of amblyopia from tobacco manifest themselves, there 
can be no hope of effecting a cure until the use of tobacco 
has been stopped altogether. Added to this essential, care 
must be given to the general health, and all other stimu- 
lants, such as whiskey, which may act deleteriously upon 
vision, must be prohibited. After a sufficiently long period 
has elapsed to peiinit the tissues of the optic nerve to re- 
gain their vigor and to allow for the elimination of the 
poison of nicotine from the system, it is sometimes safe 
to permit of a continuance of smoking under strict 
curtailment. 

Alcohol. — Alcohol, and we are now speaking not of 
wood or methyl alcohol, that form of alcohol which is used 
in the arts and whose injurious effects upon the eyes we 
have already noted, but of ethyl alcohol, the essential prin- 
ciple contained in beer, wines, and liquors, and other in- 



276 HYGIENE OF THE EYE 

toxicating beverages, has a two-fold action upon the eyes. 
When taken in toxic dose, that is to say, when enough 
whiskey or beer is imbibed to produce drunkenness, the 
accompanying double vision and: uncertainty of the posi- 
tion of things is induced by the action of the alcohol on 
the nerve centres controlling the movements of the muscles 
of the eyes, just as the muscles of locomotion are affected. 
As soon as the effects of the spree are gone, however, vision 
clears, and no permanent danger to sight remains. 

Steady and excessive drinkers, however, occasionally 
develop a form of blindness or amblyopia very similar to 
that which follow^s the abuse of tobacco; indeed, the two 
often go hand in hand, for heavy drinkers are often heavy 
smokers and vice versa, for the habitual smoker often 
craves liquor in some form to stimulate his heart which 
has been depressed by nicotine. Like the disturbance of 
vision from tobacco, the cloudiness from alcohol occurs only 
in those who have long indulged themselves in the exces- 
sive use of the stimulant, and usually manifests itself only 
after the general health has been impaired by their ex- 
cesses. The same fibres of the optic nerve are involved 
as in tobacco amblyopia, and the only hope of amelioration 
is complete abstinence from the use of alcohol in any form. 

The avoidance of this form of visual disturbance con- 
sists, naturally, in the temperate use of all kinds of bever- 
ages containing alcohol, particularly those, such as whiskey 
and brandy, which contain large percentages of this poison. 
One attack should determine strict abstinence for life, for 
a recurrence is more likely than after tobacco amblyopia 
and a complete cure more difficult to obtain. 

Tea, Coffee, and Chocolate. — In rare cases, due to 
the absorption by the body of poisonous substances con- 



EFFECT OF CERTAIN BEVERAGES AND DRUGS 277 

tained in them, the excessive use of tea and coffee has 
caused partial blindness. Fortunately, such visual disturb- 
ances are rare. JNIore common are those which arise from a 
general impairment of digestion, in certain individuals who 
possess what is termed an idiosyncrasy for these substances, 
and which is seen oftener from drinking chocolate, when 
certain visual phenomena appear which are akin to those 
already described under migraine, i.e., flashes of light, 
motes, half vision, etc. Naturally, individuals with such 
an idiosyncrasy should abstain entirely from these bever- 
ages and the baneful effects from the excessive use of tea 
and coffee should be combated by temperance in their 
consumption. 

Drugs. — The excessive use of certain drugs may be 
injurious to vision. Mention can be made here of only the 
most common. Blindness from quinine usually occurs in 
malarial districts, whose population are accustomed to tak- 
ing large quantities of the drug without medical super- 
vision. The loss in vision is generally accompanied by 
other symptoms of quinine poisoning, viz., ringing in the 
ears, dizziness, fulness in the head and at times stupor 
or delirium. Blindness may be immediate, or come on 
gradually. The loss in sight may be so pronounced that 
not even a flash of light may be perceived when held close 
to the eyes. At other times, there may be but a moderate 
obscuration of surrounding objects. After some days or 
even weeks of blindness, vision gradually returns, though 
very rarely to anything like full acuity, the field of vision 
being much compromised by the disturbance of optic nerve 
and retinal tissues occasioned by the overdose of the drug. 

As the toxic dose of quinine varies for different indi- 
viduals and under various circumstances, no fixed amount 



278 HYGIENE OF THE EYE 

can be stated as being fatal to sight ; it behooves all, there- 
fore, to be cautious in the amount they consume, and to 
allow a sufficient interval to elapse to insure the absence of 
unfavorable symptoms before the repetition of a 5 or 10 
grain dose. 

Overdose of salicylic acid, a drug much used to con- 
trol rheumatic fever, acts upon the visual apparatus in 
much the same manner as quinine, though recovery is 
prompter and permanent danger rarer. 

Various drugs used in the eocpulsion of worms from the 
economy, such as male fern and santonin, the bases of 
many proprietary worm cures, may also exert a deleterious 
action upon vision and should only be administered under 
medical supervision. Permanent loss of sight may follow 
the ingestion of a poisonous dose of these drugs, being ac- 
companied usually by purging and vomiting. 

Iodoform, a powder used for antiseptic purposes on 
raw surfaces, may be absorbed and produce visual dis- 
turbances closely akin to those of tobacco. Loss of sight is 
usually, however, preceded by other toxic signs, such as 
diarrhoea, delirium, and fever, which should serve as cau- 
tionary measures for the withdrawal of the drug. 



CHAPTER XVIII 

COLOR-BLINDNESS 

When a beam of light is permitted to pass through 
a prism its rays are broken up into their component parts, 
and according to the wave length of these parts, a luminous 
band or spectrum is formed, which appears to the normal 
eye to be composed of many colors, namely red, orange, 
yellow, green, blue, indigo and violet. The red end of the 
spectrum, corresponding to the refraction of the longest 
light weaves, forms one end, and the ultra-violet or shortest 
waves, the other end of the spectrum. Color, therefore, as 
such does not exist in nature, but is a sensation excited in 
the eye by light waves of different lengths. The inability 
to distinguish all of the colors in the spectrum constitutes 
color-blindness. 

Although noted a hundred years previously, the first 
accurate description of this condition was given in 1774 by 
Dalton, an English chemist, who himself was color-blind, 
and who published an accurate account of his own sensa- 
tions. Among other peculiarities, he stated that he could 
note no difference between the color of a green laurel leaf 
and that of a stick of red sealing wax. To him the various 
tints of the rainbow were narrowed down to yellow and blue. 
Since. Dalton's time, numerous theories have been advanced 
to explain color-blindness, the most important of these being 
the Young-Helmholtz and the Hering theories. 

Color-blindness may be total or partial, congenital or 
acquired. To those who are totally color-blind, the world 
appears as though it were tinted with different shades of 

279 



280 HYGIENE OF THE EYE 

gray. Total color-blindness is rare, but congenital partial 
color defect is common, occurring in about 4 per cent, of 
all males. In women it is rare, occurring in about ^/lo of 
1 per cent. According to a well-known authority, color- 
blindness is hereditary and is attached to certain families; 
it may not be found in one generation, but reappears in the 
next; all children will not be aiFected, the girls especially 
escaping; when several children are affected it is traceable 
to the mother ; the kind and degree will be the same for all 
the cases in the family. In total color blindness, con- 
sanguinity in the parents has been traced in 12.5 per cent, 
of the cases. Partial color-blindness may vary greatly, but 
the inability to differentiate between red and green is the 
most common. 

Acquired color-blindness may attend any disease within 
the eye which causes retinal change or interferes with the 
proper conduction of impulses from the retina to the visual 
brain centres. The most common cause of acquired color- 
blindness is disease of the optic nerve due to the immoderate 
use of alcohol and tobacco, a fact of great significance, as 
will be presently recognized. 

It is essential in all cases of color-blindness that a dif- 
ferentiation should be made between the acquired and con- 
genital variety, for the first is amenable to treatment, the 
latter incurable. The diagnosis is, as a rule, readily made, 
for in the acquired form a searching examination will find 
evidence of the existing disease within the eye and visual 
acuity will also be lessened, whereas in the congenital 
form, visual acuity is unaffected and the eyes themselves 
are free from disease. 

Color-blindness is of great significance, for it disquali- 
fies for all occupations in which a proper discrimination 



COLOR-BLINDNESS 281 

between colors is an essentiaL This includes many railroad 
employees, all naval and marine officers, pilots and certain 
classes of seamen, and all occupations in the arts which 
require mixing pigments or matching colors. As a rule, 
even those who are totally red-green blind are unaware of 
the existence of this defect in their vision, and it is often 
only after a most searching test that the lack in color sense 
can be demonstrated. Although investigations and tests 
had taken place at an earlier date, it was not until 1875 
that Holmgren, a Swedish savant, instigated by a serious 
railroad accident, perfected a method by means of which 
deficiencies in the color sense might be detected. This test, 
w^hich is still in common use, determines the ability of a 
person to match various colors, a series of colored yarns 
being used for this purpose. The set of worsteds employed 
for this purpose consist of (1) three chief test colors, i.e., 
a pale green, a light pink and a bright red, (2) a series of 
match colors of lighter tints and hues which the color-blind 
are apt to confuse with the test colors. The person under 
examination is given one of the chief colors, and told to pick 
out from the mass of worsteds spread out before him, all 
colors which match it. The man with normal color sense 
will have no difficulty in discriminating, but the color-blind 
person will confuse red with greens and will add confusion 
colors of various tints, such as drabs, grays, browns, etc. 
The wool test is usually supplemented by a lantern test, 
the lantern used for this purpose being constructed in such 
a manner that a disc upon which are mounted the various 
colors used in railroads and the marine, i.e., white, red, 
green, and blue, may be superimposed over the light of the 
lantern in rapid succession. As it has been found that the 
color-blind are frequently able to differentiate between 



282 HYGIENE OF THE EYE 

colors by their diiFerent intensities of brightness, the appa- 
ratus is so arranged that a series of ground and smoked 
glasses may be used to diminish the brilliancy of the vari- 
ous test colors. The lantern is placed at 20 feet from the 
observer, in a darkened room, and the observer required to 
recognize and name colors of a size which subtend a visual 
angle of 1 minute at that distance (see p. 19) . 

Those with color-blindness, acquired from the abuse of 
alcohol and tobacco, as well as from other causes, may at 
times recognize colors correctly, provided the object upon 
which the color is exposed is sufficiently large, but are never 
able to meet the most stringent requirements of the lantern 
test. Candidates for services rendering the testing of their 
color sense a necessity are often dissatisfied with the Holm- 
gren test, as they imagine failures are due to their in- 
ability to name the various colors exposed to them, though 
the test actually makes no such demand. They are, as a 
rule, however, satisfied with the results obtained from the 
more familiar exposure of the various colored lights in the 
lantern. 



CHAPTER XIX 

THE BLIND. BLINDNESS FROM AN ECONOMIC 
AND SOCIAL POINT OF VIEW. THE EDUCA- 
TION AND EMPLOYMENT OF THE BLIND 

By O. H. Burritt, M.A. 

principal, pennsylvania institution for the in- 
struction of the blind, philadelphia, pa. 

In the preceding chapters all the emphasis has been 
placed, as it should be, upon doing everything possible to 
conserve vision. But when everything kno^vn to science 
has been done to prevent blindness, disease and accident 
will still take their toll and it will be the sad duty of the 
oculist to tell the fond mother that her little one will never 
see again ; or perchance a strong man that he must prepare 
himself for oncoming blindness. The purpose of this chap- 
ter is not to minimize blindness — the loss of sight is always 
a calamity — but to bring a message of hope and cheer to 
those who must and can learn to live useful lives in spite 
of blindness. We shall learn that total blindness need not, 
does not, mean total despair. 

Causes of Blindness. — As the causes of blindness 
have been so fully considered in preceding pages, mention 
need be made here of only one of the most common causes 
of blindness in those of school age, i.e., between the ages of 
five and twenty. The most prolific of all the causes of 
blindness in children is that scourge of infancy, ophthahnia 
neonatorum (babies' sore eyes) , which does its damage usu- 
ally within three or four days after birth. The National 
Committee for the Prevention of Blindness found that of 

283 



284 HYGIENE OF THE EYE 

3334 pupils enrolled during the school year 1914-15 in 30 

residential schools for the blind, 740, i.e., 22 + per cent., 
were the victims of ophthalmia neonatorum; and that 91 
of the 602, i.e., 15 per cent., of the new admissions in 28 
of these schools were blinded by this disease. It made blind 
71 of 200 (35 per cent.) of the pupils enrolled in the 
Philadelphia school December 1, 1916, and was the cause 
of blindness of 27 per cent, of all pupils enrolled during 
the past 25 years. A conservative estimate is that one- 
fourth of all the children who reach our schools for the 
blind are victims of this dire disease. And the horror of it 
all is that blindness from this cause is almost wholly un- 
necessary ; for it is preventable in almost every case. Pre- 
vent blindness in this one-fourth of the pupils enrolled dur- 
ing the last school year (1915-16) and we could close one- 
half of the smaller residential schools for the blind in the 
United States. Stop blindness from this one cause and 
the reduction in the number of pupils would enable us to 
close the schools supported by the following States: Cali- 
fornia, Colorado, Connecticut, Florida, Georgia, Idaho, 
Kansas, Louisiana, Mississippi, Missouri, Montana, Ne- 
braska, New Mexico, North Dakota, Oklahoma, Oregon, 
South Carolina, South Dakota, Utah, Washington, West 
Virginia, Wisconsin, and Vermont. And as the annual 
per capita cost of educating a blind child in a residential 
school is now easily $350 in excess of that of educating a 
seeing child, the annual saving to the tax payers of the 
United States in the case of those children who are un- 
necessarily blind from this single cause would be at least 
$430,000. 

Number of Blind Persons. — No accurate statement 
as to the number of blind persons in any unit of govern- 



THE BLIND— EDUCATION AND EMPLOYMENT 285 

nient can be made. That such information is lacking when 
so much attention is given to the collection of statistical 
data concerning every sort of enterprise is due to two prin- 
cipal causes : the lack of a generally accepted definition of 
blindness and of an accurate method of enumerating our 
blind population. According to the exact and scientific 
definition of the oculist, only he is blind to whose brain the 
optic nerve conveys not even the sensation caused by a ray 
of light. If this definition be accepted, the number of blind 
is small indeed. But for the determination of such prac- 
tical questions as education and employment, we must in- 
clude in any enumeration of the blind those who have light 
perception, see shadows or have varying degrees of defec- 
tive vision. There is substantial agreement among oculists 
that children who possess not more than one-tenth normal 
vision should be taught by the methods used in the educa- 
tion of the blind ; and this definition of blindness is generally 
accepted by educators of the blind. If blindness be thus de- 
fined the number of blind persons will be very much larger 
and the ratio of the blind to the general population will be 
perhaps as 1 : 2000. If we accept the figures of the United 
States census of 1910, the ratio for the entire country is 
approximately 1 :1600; for the State of Pennsylvania, 
1 : 1700. 

Classification by Age axd Sex. — The Xew York 
State Commission on the Adult Blind in 1903, classifying 
the 6008 persons returned as blind by the United States 
census enumerators of 1900, found that of each 100 of the 
l)lind population 10 were under 21 years of age; 23 were 
between 21 and .50; 14 between .50 and 60; and .53 over 60 
years of age. Other studies seem to warrant the general 
statement that in the United States of every ten blind per- 



286 HYGIENE OF THE EYE 

sons one is under 20, four are between 20 and 60, and five 
are over 60 years of age. Of every 100 blind persons ap- 
proximately 55 are men ; 45 women. 

1 

Provisions for the Education, Employment and 
Care of the Blind 

In whatever phase of work for the blind he may be in- 
terested, every American returns from a study of the pro- 
visions for the blind of Europe with the feeling that the 
lot of the blind in America is far better than that of the 
blind in European countries. How varied and how gen- 
•erous these provisions are, a mere enumeration of them 
will show. For blind babies and children too young to 
attend school, nurseries; for children of school age, resi- 
dential schools and classes providing for the co-education 
of blind and seeing; for able-bodied men and women of 
working age, not only working homes where blind men 
and women are segregated, but State commissions and 
voluntary associations to aid and encourage cooperative 
and individual effort with particular emphasis upon keep- 
ing blind people in their own homes and communities ; for 
those who desire to read, circulating libraries of embossed 
books ; for the adult blind, home teachers who go from home 
to home to teach reading and supply vocational instruction ; 
and for the aged and infirm, homes for their care and com- 
fort. While no two States make exactly the same provi- 
sions for their blind citizens, there will be found at the 
close of this chapter a brief but complete statement of all 
the provisions made by public and private philanthropy 
for the blind of the State of Pennsylvania. 

Nurseries for Blind Babies. — In the United States 
there are at least five nurseries or homes for blind children 



THE BLIND— EDUCATION AND EMPLOYMENT 287 

under school age whose combined capacity is about 125. 
In addition to these at least six States provide by law for 
the instruction and maintenance of blind babies either 
within their own borders in similar institutions for seeing 
children or outside the State. The normal place for any 
babe, seeing or blind, is at home with his mother, and no 
blind child under five years of age should be deprived of 
such care except for reasons that would obtain with seeing 
children. These nurseries provide excellent care and 
training for young children who need them as well as for 
some who are older but backward or even feeble-minded. 

The Education of Blind Children. — It is difficult 
to say where and when the idea first took root that persons 
without sight could be educated, but it is certain that it 
received its greatest initial impulse from the determined 
efforts in behalf of the blind of a son of a poor French 
weaver, Valentin Haiiy, who had demonstrated by 1785 
that the blind could be educated. Haiiy's work had a very 
direct influence upon the beginnings of educational work 
for the blind of this country. " I am convinced," said 
Julius R. Friedlander, the first principal of the Pennsyl- 
vania Institution for the Instruction of the Blind, " that 
whenever more extensive experience and a better insight 
into the ideas of the immortal Haiiy, relative to the instruc- 
tion of the blind, shall prevail, his system will be everj^- 
where introduced."^ The Philadelphia school shares with 
the schools of New York and Boston the honor of taking, 
about 1830, the initial steps to provide systematic instruc- 



■^ An address to the public at the First Exhibition of the Pupils 
of the Pennsylvania Institution for the Instruction of the Blind, 
at the Musical Fund Hall, Philadelphia, Thursday evening, 
November 21, 1833. 



288 HYGIENE OF THE EYE 

tion for the blind of the United States. The education of 
the blind, as of all so-called defectives, had its beginnings 
in private philanthropy, but an appeal was soon made for 
aid from public funds. Accordingly, it was quite the cus- 
tom to proceed with a small group of pupils to the capital 
of the State and there before the law-makers to give an 
actual demonstration of the possibilities for training those 
who could not see. Appropriations usually followed such 
demonstrations. The influence of the undertakings in 
these three centres of population and culture spread rapidly 
and the older and more populous States in quite rapid 
succession provided residential schools for their blind chil- 
dren. To-day there are forty- four residential schools in 
forty States of the Union which were attended last year 
(1915-16) by over 5000 students, the combined value of 
whose plants was stated in 1914 to be $15,224,693. 

All the older schools have passed through the experi- 
ence of admitting both children and adults, apparently the 
sole qualification for admission being that the applicant 
should be blind ; but it was early learned that this practice 
was unsound for moral as well as pedagogical reasons and 
the almost universal practice now is to admit only chil- 
dren between five and twenty-one years of age who are in 
suitable physical, mental, and moral condition to profit by 
the instruction afforded. The average age of the pupils 
in one modern residential school of about two hundred 
pupils is less than fifteen years. 

The age at admission varies greatly for three principal 
reasons : the variation in the age at which sight is lost ; the 
ignorance of parents and people generally about provi- 
sions for educating the blind ; and the reluctance of parents 
to send their children away from home at a tender age. 



THE BLIND— EDUCATION AND ElVIPLOYMENT 289 

Of the 35 new pupils received into the Philadelphia school 
for the statistical year ending May 31, 1916, 16 were under 
10 years of age; 10 were between 10 and 15 years; 7 were 
between 15 and 20; and only 2 were over 20 years. 

The length of time in school likewise varies greatly. 
Determining factors here are the age of becoming blind, 
general physical condition, mentality, ambition to learn, 
and the attitude of the home toward culture. Of 35 pupils 
discharged from the Philadelphia school for the statistical 
year ending ^Nlay 31, 1916, 3 remained less than one year; 
9 betw^een two and five years ; 9 between five and ten years ; 
and 14 over ten years (Fig. 101). 

In a well-conducted modern school for the blind in- 
struction is organized under four principal departments; 
physical, manual, literary and musical. And their impor- 
tance is about in the order named. 

Physical Training. — The blind child without train- 
ing is usually angemic, under-developed, poorly nourished, 
with flabby muscles and nervous habit movements. If his 
blindness is the result of disease, his physical stamina may 
have been lowered so that he is quite content to sit idle in a 
rocking chair ; if, as is more likely, he still retains the desire 
to share in the play and the varied activities of childhood, 
he gets small encouragement from his brothers and sisters 
or from seeing children of the same age — the blind boy or 
girl does not fit well into the active play of seeing children ; 
he is in the way. As blindness is most prevalent among 
the poor and ignorant, either because of ignorance or imder 
the stress of poverty parents fail to provide the physical 
exercise necessar}^ for the child's growth and development ; 
for it is now generally recognized that play and physical 
activity are fundamental to mental no less than to physi- 

19 



290 



HYGIENE OF THE EYE 




THE BLIND— EDUCATION AND EMPLOYMENT 291 

cal growth. And it is not uncommon for a mother to 
admit that she seldom takes her bhnd child out with her 
because " he attracts so much attention." 

For these and other equally cogent reasons the first 
problem in the education of the blind child is his physical 
development. Accordingly, everything possible in the 
school regimen is arranged to lay the foundation of his 
education in the improvement of his physical condition; 
regular hours for sleep, an ample supply of nourishing 
food, an abundance of fresh air and sunlight, a liberal 
amount of prescribed exercise, and sufficient time for free 
play. 

Upon admission his general physical condition is care- 
fully and critically examined by specialists in medicine; 
the household physician inquires into his general health, the 
laryngologist looks to the condition of his throat and ears 
and if he has adenoids or enlarged tonsils they are re- 
moved, and the oculist makes a careful examination of his^ 
eyes, and if he believes his health or his sight can be im- 
proved by an operation he recommends it. 

Recognizing its obligation to do everything possible to 
improve the physique of its pupils, the management of a 
modern school for the blind endeavors to provide as essen- 
tial features of its equipment a gymnasium, an athletic 
field, a swimming pool, and a bowling alley. There is little 
in the equipment of gymnasium or playground to remind 
one that the children who use the apparatus are deprived of 
sight — in the gymnasium, horse, wall machines, parallel, 
horizontal, and stall bars, trapeze, teeter ladder, giant stride, 
climbing ropes, horizontal ladder, running track; on the 
playground, swings, see-saws, horizontal bar, slide, and 
merry-go-round. The wide cement border will attract the 



292 HYGIENE OF THE EYE 

attention of the observant visitor who is paying his first 
visit to the gymnasium of a school for the blind. In answer 
to his query he will be told that its primary purpose is to 
inform the sightless roller-skater or dancer that he is near- 
ing the wall of the room; for the moment his foot passes 
from the wood to the cement floor he knows that he is in 
the danger zone and he immediatelj^ changes his direction. 
Incidentally this border is a convenient and safe place for 
placing the movable apparatus when not in use. 

Swimming, always an excellent form of exercise (Fig. 
102) is particularly beneficial to the blind in that in most 
forms it forces the swimmer to throw his head back, thus 
counteracting the tendency to round shoulders among blind 
people. Under good instructors every boy who remains 
in school two or three years and at least half the girls learn 
to swim, some of them becoming quite expert in the several 
varieties of strokes, in diving and in swimming under water. 

Considerable individuality is shown among bowlers 
without sight in the manner of getting their direction be- 
fore throwing the ball; one runs keeping his left hand on 
the ball rack; another stands still, getting his sense of 
direction by running his left hand a little way along the 
edge of the gutter; while a third, given his sense of direc- 
tion by the voice of the lad at the foot of the alley, seems 
to need no other guidance. Necessity being " the mother 
of invention," these boys have given each pin a number, and 
when the lad who is setting up the pins names the numbers 
still standing, the sightless bowler knows exactly where he 
should throw the ball. A record of 222 of a possible per- 
fect score of 300 points made by a totally blind boy is proof 
that blindness does not bar one from a form of exercise 
which seems to demand sight. 



THE BLIND— EDUCATION AND EMPLOYMENT 293 




294 HYGIENE OF THE EYE 

On the athletic field some of the activities of seeing boys 
are equally open to blind boys without any special devices. 
Among these are the standing ^broad jump, the standing 
high jump, three successive jumps, and the hop, step, and 
jump. Given a free open field, the blind boy can engage in 
a contest in the running broad juriip, his distance being 
measured from his " take off " to his landing point. A 
totally blind boy can put the shot and throw the hammer 
almost as well as the seeing lad of equal age and physical 
development, the only special device necessary being a 
half-circle made of wood. It is manifestly impossible for a 
totally blind boy to engage in a foot race without some 
device by which to give him his direction. The apparatus 
that has been devised to make this possible is about the only 
special device necessary in equipping an athletic field for 
sightless boys. " The idea of this was borrowed from pic- 
tures contained in the reports of the institution in Sydney, 
New South Wales, and in Edinburgh, Scotland. A three- 
strand twisted wire cable, as light as is consistent with 
strength, is stretched breast high between well guyed end 
posts one hundred and ten yards apart. The little sagging 
towards the middle is of no consequence. The runner holds 
in one hand a wooden handle attached by a short flexible 
chain to a ring on the wire. As he runs the ring slips along 
and both the feel and the sound it gives enable him to hold 
his course. So far so good ; but how to afford a proper stop 
at the one hundred yards mark was not ascertained until 
we had stretched across the track at this place a fringe 
made of hammock twine to strike the runner in the face, 
much as the low-bridge indicator does the men standing on 
top of moving freight trains. This fringe stop, which is 
entirely satisfactory, covers the two parallel cables of our 



THE BLIND— EDUCATION AND EMPLOYMENT 295 

running track. Starting as they always do from the same 
end, Wind boys can practice running as much as they please ; 
but in all real racing, one instructor starts a pair by pistol 




Fig. 103. — One hundred vard dash. Start. 




■ Fi3. 104.— Finish. 

shot while another instructor, standing at the one hundred 
yards mark, times them with a stop watch" (Figs. 103 
and 104).' 



^ Edward E. Allen in the Seventy-fourth Annual Report of 
the Pennsylvania Institution for the Instruction of the Blind. 



296 HYGIENE OF THE EYE 

Blind boys get a great deal of sport and much pleas- 
urable exercise from a modified form of football. To in- 
troduce the element of competition they usually choose 
sides, seeing to it that each team contains an equal number 
of totally blind boys and at least one with some sight. When 
it has been determined by lot which side shall " kick off " 
from the centre of the field, the efforts of each team are 
directed toward kicking the ball over the goal of the oppos- 
ing team. To prevent the ball from passing over its goal 
the team depends chiefly upon their team mate who has 
sufficient vision to see the ball when in motion, although the 
captain has directed his sightless team mates to stand at 
possible strategic points with the hope that the opposing 
player who, four chances out of five, is unable to see where 
any member of the rival team is standing, will chance to 
kick the ball against one of them who thus contributes what 
he can toward the stopping of the ball. But the totally 
blind player contributes his major share to the team work 
by kicking the ball which he oftentimes does as well as, 
and sometimes better than, his team mate with some sight. 
The number of times each team kicks the ball over the 
goal of the other, within the time limits, determines the 
final score. 

The Training of the Hand. — As the hand must do 
duty for the eye, particular emphasis is laid at all times 
upon the training of the hand. This training is begun 
among the younger children by making large use of the 
kindergarten occupations. Clay modeling and drawing, 
which blind children do with upholsterer's brass-headed 
tacks on '' cushions " filled with excelsior and covered with 
denim, are particularly valuable because they enable the 
child to express his ideas of objects which he has studied; 



THE BLIND— EDUCATION AND EMPLOYMENT 297 




298 HYGIENE OF THE EYE 

paper folding and cutting patterns with blunt pointed 
scissors; weaving with strips of wood about three-eighths 
of an inch wide with half -inch skirt braid as warp ; string- 
ing kindergarten wooden beads on heavy shoe laces fol- 
lowed by the stringing of nature materials, such as cran- 
berries and various kinds of garden seeds ( after soaking in 
water) ; sewing with shoe laces through holes one-fourth 
inch in diameter, followed by the use of coarse blunt 
worsted needles with large roughened holes through heavy 
cardboard — an unconscious but valuable training for finger 
reading ; raffia for winding over a firm foundation, making 
such ob j ects as napkin rings and picture frames ; and reed 
basket making, made possible for younger children by the 
introduction of wooden bottoms for baskets and trays — 
these are the principal occupations by which the hands of 
the little blind child are trained during his first years at 
school. To work of this kind, so fundamental in all his 
education and so vital in his subsequent employment in the 
development of facility in the use of his hands, he should 
devote at least one-third of his time in the school-room 
(Fig. 106). 

With this foundation the blind girl begins her course 
in the manual arts, which includes hand-sewing, knitting, 
crocheting, and machine sewing. In some schools girls are 
taught to cane chairs with the double purpose of securing 
a greater variety of manual occupation and of utilizing it 
as a means of contributing towards their livelihood after 
leaving school ; for under favorable conditions blind women 
have been able to earn very creditable amounts from this 
handicraft. Some learn to weave rag carpet. In a few 
schools the course in manual occupations includes also 
working in wood with the simplest tools. No course in 



THE BLIND— EDUCATION AND EMPLOYMENT 299 




300 HYGIENE OF THE EYE 

manual training for blind girls is complete without in- 
struction in the elements of domestic science or home keep- 
ing. Where the school is built on the cottage plan, the 
ideal course combines the theoretical instruction of the class- 
room with the practical application of such instruction in 
the necessary daily routine of the life in the cottage ( Fig. 
107). 

For the training of the hand of the boy a thorough 
course in manual training is provided of which the chief 
element is working in wood, or wood-sloyd. This course 
should extend over at least four years of his elementary 
course. By it he is laying the foundation for his life 
career; these are the years during which his muscles are 
most responsive to training; no subject in the school cur- 
riculum is of more importance to his success in life. But 
the training of the hand must not cease after four years of 
manual training. Our problem is to provide sufficient 
variety of training to hold the boy's interest that he may 
continue to develop facility with his hands. So caning is 
introduced at the appropriate time and instruction in this 
manual occupation proceeds simultaneously with wood- 
sloyd. By this time his capabilities along manual lines are 
sufficiently known to guide the teacher in planning his 
subsequent hand training. If he has good use of his hands 
and has shown in his general musical training some ability 
to judge pitch, he is given a trial at piano tuning. If he 
lacks ability along either line, he should not undertake to 
prepare for tuning. The usual manual occupations re- 
maining for him are weaving rag carpet and rugs and the 
making of brooms. 

Literary Department. — From what has been said 
it should now be quite evident that the foundation of a blind 



THE BLIND- 



EDUCATION AND EMPLOYMENT 301 




302 HYGIENE OF THE EYE 

child's education must be laid in the upbuilding of his body 
and in the training of his hand. But an essential element 
in any school is a course of study and this exists in one 
form or another in all schools for the blind. Instruction 
is usually provided in nearly all subjects taught in the 
public schools through primary, intermediate and grammar 
grades, several schools maintaining kindergartens. Most 
schools provide instruction in from one to four years of high 
school subjects. A few of the more capable pupils are 
encouraged and assisted in every way possible to supple- 
ment the education obtained in a school for the blind by 
continuation courses at normal school, college, university, 
or school of theology. 

Reading. — As an instrument for the acquisition of 
knowledge through books, the ability to read is a prime 
essential. Valentin Haiiy " was the first — ^of whom we 
have any record- — who conceived the idea of systematically 
teaching the blind to read by means of raised characters.^ 
The story of the way in which Haiiy was aroused to pro- 
vide for this need of the blind is so interesting and instruc- 
tive and the results of his efforts for them have been so far- 
reaching in their effects that it is reproduced here. 

" In 1771 St. Ovid's Fair was the chiefest popular at- 
traction. Daily at this time when the crowds were greatest, 
one of the booths had been mounted by a certain Valindin, 
an impressario of genius after his style, whose success had 
marked these public shows. Valindin had gathered to- 
gether a number of blind men, whom he had given in charge 
of a crowd of rowdies. These fellows were so enthusi- 
astically enjoying the sport that they would have demol- 

3 " History of the Education of the Blind," by W. H. IlHng- 
worth, p. 5. 



THE BLIND— EDUCATION AND EMPLOYMENT 303 

ished the booths in their exuberance, so that it became 
necessary to organize a cordon of guards for protection. 
Valentin Haiiy saw the exhibition. He followed the 
throng and here, depicted by himself, is the scene which 
he beheld and the impression which it made. 

" ' In the month of September, 1771, they had placed in 
a cafe at St. Ovid's Fair, six men, chosen from those who 
were reduced to the humiliating necessity of begging their 
daily bread; and to attract attention and to excite public 
sympathy, they employed an instrument which if the hearer 
were gifted with a musical ear, and even more if he had a 
tender heart, would drive him from the inharmonious 
sounds, that were designed to gain a reward of talent. 
These men had been grotesquely costumed in robes and 
long-pointed hats. On their noses they had put huge paste- 
board spectacles without glasses. Placed before a desk on 
which were music and lights, they executed a monotonous 
chant in which the tenors, the bases, and the violins all took 
the same part. There was nothing to palliate the insult that 
they had put upon these unfortunates, who were surrounded 
by emblems of the grossest ignorance, as, for instance, in 
placing behind their leader the expanded tail of a peacock, 
and on his brow the headdress of Midas. 

" ' Why was it that a scene so dishonorable to humanity 
did not perish the instant of its conception? Why was it 
that poetry and picture should lend their divine ministra- 
tion to the publication of this atrocity? Ah! it was with- 
out doubt, that the scene reproduced before my eyes, and 
carrying into my heart a profound sorrow might inspire 
and arouse my soul. Yes, I said to myself, seized by an 
exalted enthusiasm, I will substitute the truth for this 
mocking parody, / will make the Mind to read! I will put 



304 HYGIENE OF THE EYE 

in their hands volumes printed hy themselves. They will 
trace the true characters and will read their own writ- 
ing, and they shall he enabled to execute harmonious 
concerts/ " ^ 

More than ten years passed before Haiiy was able to 
reach the goal of printing in relief for the blind. All the 
early efforts to provide an embossed type were directed 
toward making tangible the simpler forms of type in gen- 

abc 3 e/qfttj,k.Liuao 
parstayw x-ij z 

Fig. 108. — Facsimile of type used by Valentin Haiiy. 

eral use by the reading public. So long as men with sight 
worked at the problem, this was the logical thing. Haliy's 
adaptation was the following (Fig. 108) : 

The first alphabets used in the American schools were 
some form of " line type " which were simply modifications 
of the ordinary fonts used by printers. Two forms were 

^ " The Blind as Seen Through Blind Eyes," by Maurice 
de la Sizeranne, p. 56. 



THE BLIND— EDUCATION AND EMPLOYMENT 305 

perfected: one, in the Pennsylvania school, known as the 
Philadelphia Line Type which retained the capital letters 
and used rounded forms of small letters, in which was pro- 
duced in November, 1833, the Gospel of Mark, the first 
embossed book for the blind printed in America ; the other, 
in the JNIassachusetts school, known as the Boston Line 
Type, which discarded capital letters and introduced the 
principle of angularity into the letters in the belief that 
they were more tangible. These types continued in use 
until a blind man, Louis Braille, by chance another son of 
France, devised an alphabet by a purely arbitrary arrange- 
ment of dots. The enormous advantage of a " dot " over 
a " line " system as a medium of instruction lies in the fact 
that it can be written as well as read, no practical means 
having been devised for writing any line system. Braille's 
system is based upon six dots arranged two horizontally, 
three vertically, thus • J of which sixty-three combinations 
are possible. This system was adopted in France, was in- 
troduced later into England and somewhat later into the 
L^nited States. Various modifications of this arrangement 
have been devised, but the basic principle of Braille's cell 
obtains wherever education for the blind is provided. One 
modification, devised by another blind man, this time an 
American, Joel W. Smith, in use by abovit one-half of the 
schools in this country, sometimes referred to as '' revised," 
sometimes as " scientific " Braille, but more generally 
known as American Braille, is as follows (Fig. 109) : 

Another modification of Braille's system, known as 
Xew York Point, devised by Dr. Buss and perfected by 
Mr. Wait at the Xew York (City) Institute is based upon 
a cell only two dots high, thus : :, which is capable of in- 
definite extension horizontally. This system was formu- 

20 



306 HYGIENE OF THE EYE 

AMERICAN BRAILLE 

To write on a Braille tablet begin at the right; to read reverse th? sheet and 

begin at the left. In either case the six points ( • • 1 of which the characters are 

formed, are numbered from the top, 1, 2, 3, for the first vertical rov/, and 4, 5, 6, 
for the second. 

ALPHABET. 

abcdef ghijklm 

• • • •• •• •• • •••• • •• 

• •• • •• •• •• • ••• • 

• • • • • • 

nopqrstuvwxyz 
• • ••••••••• • • « • •• 

• •• • • •••• ••• 

•• •• • •••• *••• • 

To capitalize a letter prefix to it points 3 and G ( • • / • 
MARKS OF PUNCTUATION. 

■ ,;:.?!-()'- 



• • • • 



The apostrophe is point 4. The other marks, except the exclamation, are 
formed of points 2, 3, 5 and 6. 

When two or more initial letters requiring the capital sign occur together, the 
space which separates words may be omitted; the period which follows the first letter 
then becomes also the prefix, or capital sign, for the next; thus, 

!• •• • F. R. S. 



NUMERALS. 

When alone or in combination the following letters, if prefixed by the numeral 

sign ( • ] become numbers. 

1234567890 

• • •• •• • •• •• • • • 

« • •• •• ••• •• 

1 : • 46 : •: :* 235 ::••*. 

•• •• •• 

Fig. 109. — American Braille alphabet. 



THE BLIND— EDUCATION AND E^VIPLOYMENT 307 

lated earlier than the xAmerican Braille and is used in fully 
one-half of the schools on this continent. 

Between these two dot types, the battle of supremacy 
in America has been waged for a quarter of a century. For 
about fifteen years a committee of capable blind people has 
been working for a uniform type with the hope that an 
agreement with the English can be reached so that there 
shall be a uniform type for the blind of the English-speak- 




Fig. 110. — Interlining Braille slate. 



ing world. The world war has interfered with the prog- 
ress of the work for uniformity of the committees appointed 
in England and America, but it is believed that mutual 
concessions will ultimately lead to uniformity. 

Writing which can be read by the fingers is done by 
means of a stylus with which the writer pushes the paper 
into " pits " drilled into a metal base, the number corre- 
sponding to the six dots of the Braille cell, the stylus in the 
writer's hand being guided by cells punched into a metal 



308 



HYGIENE OF THE EYE 



guide. This method is somewhat slow, as it is possible to 
make but a single dot at a time, but those who have good 
use of their hands, with constant practice, write with re- 
markable speed. A small machine resembling somewhat 
a typewriter but with keys corresponding to the number of 
dots in a cell has been invented by which the operator can 
make an entire character at one stroke. By this it is possi- 
ble to produce embossed characters with greater speed and 
facility (Figs. 110 and 111). 




Fig. 111.— Hall Braille writer. 



Pencil writing can be learned by totally blind people if 
sufficient time be given to it, but many educators believe 
that it has insufficient value to warrant the time and effort 
involved for one who has never seen to learn to produce 
legible writing, particularly in view of the moderate price of 
typewriters which can be easily mastered by blind people. 
Pencil writing has been taught most systematically and 
continuously in this country at the Perkins Institution now 
located at Watertown, Mass. That one who has been 



THE BLIND— EDUCATION AND EMPLOYMENT 309 

totally blind from early childhood can produce a perfectly 
legible letter is shown by the reproduction of an invitation 

dtr UowE nzf^dLjia LLuir 
CQA-dLaLlij LyLviit^ u uu in 
If c L JiEactii ai: a en. h.z- 

rTLfc h. tnLTimcvL't -to, Irr 

niLiLdLTUT, Pclr^iia^Tj 
T I 1^ f k^ art ^ ua h.tc:)L 

Fig. 112. — Facsimile of pencil writing in "square hand" by a totally blind girl, a pupil 
of the Perkins Institution for the Blind, Watertown, ^lass. 

written by a girl pupil of that school, blind since two years 
of age, who has studied pencil writing about ten years 
(Fig. 112). 



310 HYGIENE OF THE EYE 

Languages, whether Enghsh, modern foreign, or 
ancient classical, can be reproduced for finger readers. It 
is only necessary to assign dot characters for various ac- 
cents and modified vowels, or for the entire alphabet as in 
the case of Greek, and the blind student can become as pro- 
ficient a linguist as his seeing classmate. The chief ob- 
stacles to a wealth of text-books and literature for the blind 
are the cost of production and bulk of embossed books 
which is referred to later in this chapter. 

Mathematics in nearly all its forms is as possible for 
blind as for seeing students. By means of an arbitrary 
assignment of characters the ten arithmetical digits and 
the signs of operation are provided for. In the same man- 
ner the need is met for the additional characters necessary 
for algebra and geometry and the higher mathematics. 
Short processes in arithmetic and mental arithmetic are 
most advantageous to the blind student and should be 
utilized to the fullest extent. Some blind students have 
done such notable work in mathematics as to seem to war- 
rant the statement that the blind excel in this science ; but 
the truth is there are about the same differences among 
blind as among seeing students ; some excel in mathematics, 
others in languages — it is a matter of individual taste and 
capacity, a question wholly apart from the possession of 
sight or the lack of it. 

The elementary facts of form study and drawing can 
be taught by special devices. One method is a home-made 
*' cushion " ; a shallow box, whose sides are two or three 
inches deep, is filled with hair or excelsior which is covered 
with ordinary denim cloth. On this " cushion " the sev- 
eral kinds and sizes of upholsterer's tacks are used for the 
various kinds of lines. 



THE BLIND— EDUCATION AND EMPLOliMENT 311 




312 HYGIENE OF THE EYE 

It is probably true that no subject in the curriculum 
of all schools is so generally poorly taught as geography, 
and this is no less true of schools for the blind. The de- 
scriptive portions of this sub j ect are as easily taught to 
sightless as to seeing pupils. But it is exceedingly difficult 
if not impossible to convey, to those blind from birth or 
early childhood who consequently have no visual images, 
any correct notions of the graphical portions of the subject. 
Outline maps are made on metal plates from which repro- 
ductions upon paper are made in sufficient quantities that 
each pupil can have one under his fingers, but it is doubt- 
ful whether the pupil gets any very exact idea from these. 
In this matter, however, he may be no worse off than the 
seeing child who, it is well known, acquires singularly in- 
correct notions from the map. Probably the most satisfac- 
tory aids to map study in a school for the blind are the 
dissected maps which enable the pupil to acquire more ac- 
curate ideas of form and relative size. Maps can be drawn 
by means of the special device for drawing, already de- 
scribed, but the process is so slow and the results are so in- 
commensurate with the labor involved that it possesses 
doubtful value (Fig. 113). 

History can be as easily taught blind as seeing pupils. 
The chief difficulty is the limited number of books which 
makes impossible any extended reading or research work, 
except by the few who can afford to employ a reader. But 
as blind people must get a much larger proportion of their 
information through the ear than through the eye, some 
acquire the habit of attention so that they are able to get 
as much from one reading of a historical or literary passage 
as many seeing people do from two readings. This power 
is not, however, to be considered as inherent in blindness; 



THE BLIND— EDUCATION AND EMPLOYMENT 313 

and in the blind as a class there are the same individual 
diiFerences in the power of attention as among those who 
see. 

The facts of the various natural and physical sciences 
can be acquired by blind pupils who can follow and even 
themselves perform many of the simple experiments which 
seem to require sight. Indeed, an enthusiastic teacher of 
these sciences can give totally blind pupils a considerable 
fund of information from clear and detailed description 
of experiments which the teacher performs in the presence 
of the class. 

Typewriting is taught in most schools for the blind, 
almost every make of machine being used and usable by 
sightless operators. Shift-key machines are doubtless best, 
as their keyboards are more compact and liability to errors, 
due to striking the wi'ong keys, is reduced by nearly one- 
half. The blind operator is entirely at home with the 
" touch system " now generally taught in schools of busi- 
ness ; for no other system is possible for him. Contrary to 
popular belief, no special marking of the keys is necessary ; 
he learns his keyboard precisely as does the seeing oper- 
ator who learns the " touch system." Blind people can 
and do learn to write almost without error. The typewriter 
is the best means of communication between blind people 
and their sighted friends. The ability to use the typewriter 
well can be acquired by the expenditure of much less time 
and effort than is necessary to be able to write legibly with 
the pencil. Cheapness, simplicity of construction, dura- 
bility, and portability are the chief desiderata in a type- 
writer for the bhnd. The folding typewriter recently 
manufactured is a boon to them. The chief if not the only 
argument against the typewriter and in favor of pencil 



314 HYGIENE OF THE EYE 

writing is the relative cost; everyone can be supplied with 
pencil and paper, only the few can afford to own a type- 
writer. But as second-hand and rebuilt machines can be 
purchased at a nominal cost, this argument loses much of 
its force. 

It has been demonstrated that a blind person who pos- 
sesses the other qualifications can do work in typewriting 
that has commercial value, particularly at such work as type- 
writing from dictaphone records. Probably no other school 
in the world has developed so highly efficient a typewriting 
department as the Royal Normal College for the Blind in 
London, England. Several graduates of that school hold 
positions in offices which they have won in competition 
with seeing typists because of the superior excellence of 
their work. A few totally blind operators are filling re- 
munerative positions in this country. In order to attain 
success one must be able to do almost perfect work and 
be fortunate enough to secure a position where he is not 
required to file correspondence, but can spend his entire 
time at typewriting. 

The Musical Education of the Blind. — It is popu- 
larly believed that the blind are more musical than those 
who see; but we are no more warranted in generalizing 
about the musical abilities of the blind than about any other 
characteristics or abilities popularly attributed to them. 
So far as the pupils of our schools are concerned, the truth 
is that the general educational value of music and its par- 
ticular value to those whose channels of enjoyment and ap- 
preciation are restricted by the lack of sight are recognized, 
and the aim is to provide adequately for instniction along 
musical lines. In a residential school the atmosphere is 
saturated with music. There is choral and group singing, 



THE BLIND— EDUCATION AND EMPLOYMENT 315 

singing at the daily prayer service, individual voice culture 
for a few of the most talented, instruction in piano playing 
and, for a few with special talent, in organ playing. Some 
schools add to these instruction on the violin, guitar, and 
other stringed instruments. Little wonder is it that in such 
an atmosphere those who possess musical ability are dis- 
covered and provided with the very best musical education 
obtainable! ]Music is preeminently the one art in the en- 
joyment and appreciation of which blindness is no handi- 
cap. Here blind and seeing are on a plane of entire 
equality. 

The difficulties are infinitely greater in following music 
as a vocation. A talented few become church organists; 
but one must possess superior ability and must put forth 
almost herculean effort to meet the demands made upon 
an organist of a modern church. A conspicuous example 
of a blind man eminently successful as a church organist 
is the late David Duffle Wood, of Philadelphia, who, 
though totally blind from early childhood, by the sheer 
force of will coupled with musical ability, broke asunder 
the bonds which his blindness imposed upon him and be- 
came one of the most eminent musicians of the city in which 
he lived. After securing his education at the Pennsylvania 
Institution for the Instruction of the Blind, he became the 
organist at St. Stephen's Protestant Episcopal Church, 
which position he held for forty-six years, during twenty- 
five of which he was its musical director. During much of 
this time he was a member of the staff of one of the city's 
best schools of music and he was in constant demand as a 
teacher of the organ. 

The moving picture theatre offers a wider field for 
musical talent and more remunerative employment, and 



316 HYGIENE OF THE EYE 

not a few successful organists have left the church organ 
bench for this better compensating, if less dignified, field of 
labor: but to succeed in this field one who is totally blind 
must have the aid of a person with sight. A still larger 
number become teachers of the piano; some in schools for 
the blind, some as private teachers of seeing children. Sev- 




FiG. 114. — Senior pupils teaching seeing pupils. At the clavier and piano. 

eral schools now provide normal courses for those who have 
the inclination and the ability to teach, in which the teacher 
in training is instructed in the methods employed in teac-li- 
ing seeing children and actually teaches them imder the 
supervision of the experienced teachers of the music staff. 
For blind people who possess the requisite ability, musical 



THE BLIND— EDUCATIOX .\XD EMPL0Y:\IEXT 317 

appreciation, personality and perseverance, the profession 
of music offers a field for useful and remunerative em- 
ployment ( Fig. 114). 

COEDUCATIOX OF BlIXD AXD SeEIXG IX PuBLIC 

Schools. — What has been said so far about the education 
of the blind has had reference to their training in resi- 
dential schools, which was the only method in vogue until 
the twentieth century. To the city of Chicago belongs the 
credit of undertaking, in 1900, the experiment of educating 
blind children in classes with those who see. This plan was 
in operation during the school year 1915—16 in at least ten 
cities in which there were enrolled 497 pupils. 

The usual plan of conducting these classes is as follows : 
A room, equipped with the special devices needed by blind 
pupils, is placed in charge of a special teacher whose first 
duty is to see that the pupil masters the devices that are 
necessary for him to be able to use almost automatically 
before he can go to the grade room, to which by his age and 
attainments he belongs, and share in the recitations with 
his seeing classmates. He must learn to read and to write 
his dot type, to use his type slate ( a special device used by 
the blind in arithmetic and algebra), and later to operate 
a typewriter. As soon as he can read and wa'ite his dot type 
he can take part in the recitations in reading, spelling, 
language, geography, history, and similar subjects. One 
important and arduous dutS^ of the special teacher is to see 
that the blind pupil is provided with a reading book and 
wherever possible with an embossed copy of all the material 
used by his seeing classmates. The special teacher inter- 
lines for the grade teacher his written work in language, 
history, geography, etc. ; for everything must be done to 
make the blind child a welcome member of the class, and 



318 HYGIENE OF THE EYE 

one essential is that he add as little as possible to the duties 
of the grade teacher having from forty to sixty pupils. As 
he progresses he can save the time of both special and grade 
teacher by using the typewriter for his " written " work. 
As the assistance by the special teacher must be largely in- 
dividual and as all of her pupils may belong to different 
grades, the membership of these classes is usually restricted 
to ten pupils. 

While this method is still in an experimental stage it 
is only fair to its advocates to say that the advantages 
claimed for it have much to commend it ; it keeps the child 
constantly among seeing children and in the normal atmos- 
phere of his home instead of removing him for a time to a 
residential school; it places the responsibility for his care 
and support upon his parents; and it is more economical. 
Obviously such a plan is possible only in the more populous 
centres. 

This plan, however, violates the two most fundamental 
needs in the education of the blind which were stated earlier 
in this chapter, in that it fails to make any adequate pro- 
vision for the physical and manual training of the pupils. 
Under this method, too, is lost all there is of value in hav- 
ing pupils continually in a musical atmosphere, and it is 
much more difficult to provide them with opportunities for 
serious musical study. In other words, it so far provides 
chiefly for the literary education of the blind and this it 
seems to do well. In all fairness it ought to be said, how- 
ever, that private associations interested in the experiment 
have done what 'chey could to supply these needs and they 
have succeeded admirably when the difficulties are fully 
understood and appreciated. Altogether the plan has much 
to commend it. Between those who advocate it and those 



THE BLIND— EDUCATION AND EMPLOYMENT 319 

who favor the residential school plan there is no conflict; 
rather the advantages of both methods are recognized and 
the ideal arrangement in the minds of the leading advocates 
of both is that which will give each child, who can possibly 
avail himself of them, the advantages to be derived from 
both methods. 

The Higher Education of the Blind. — No institu- 
tion for the higher education of the blind, corresponding to 
Gallaudet College for the advanced training of the deaf, 
has been provided and it is well that it is so. There is sub- 
stantial agreement even among those who believe in the 
advantages of the residential school that the period of resi- 
dence in them should be shortened rather than lengthened. 
Having been surrounded during ten or twelve of his most 
impressionable years by his schoolmates similarly afflicted ; 
having been thrown but little, if at all, upon his own re- 
sources but accustomed to have all decisions made for him, 
it is far better for him to secure his advanced training 
among those who see. Where residential schools are situ- 
ated near a high school the more capable pupils sometimes 
attend the high school. A few of the more capable and 
ambitious attend normal school, college, or university, 
sometimes as resident students, sometimes as day pupils 
from the special school. As only those are encouraged to 
attempt advanced courses of training who are known to 
possess superior ability, they usually maintain a very satis- 
factory grade of scholarship. While the embossed print- 
ing presses do what they can to supply for these students 
advanced text-books in tangible type, they must usually 
content themselves with embossed copies of their texts in 
foreign languages and mathematics, relying upon readers 
for the preparation of their lessons in other subjects. In 



320 HYGIENE OF THE EYE 

order to aid these worthy young people in obtaining a higher 
education, six states provide a limited amount of funds that 
may be expended for a reader or for board and tuition or 
for both. With his course satisfactorily completed the 
young man or woman is still confronted with the problem 
of making his way in the world. Nevertheless, the results 
are highly encouraging: of 18 young men and women, 
graduates of one of the three oldest residential schools re- 
ferred to earlier, who had taken advanced courses of in- 
struction, all are rendering useful service in their chosen 
vocations and are self-supporting. Lewis B. Carll, an 
eminent blind mathematician, stood second in the class at 
Columbia College which his classmate, the late Seth B. 
Low, led. Capable and worthy young people without sight 
should receive every possible encouragement to secure a 
higher education. 

Embossed Books for Finger Readers. — ^When Haiiy 
was providing his pupils with books in a tangible type late 
in the eighteenth century, when the embossing presses in 
Philadelphia and Boston began printing soon after the 
opening of their schools, the process was a very slow and 
expensive one. Nor was there any material advance in the 
production of embossed literature until late in the nine- 
teenth century. The adoption of the dot types was soon 
followed by the invention of machines for producing metal 
plates which are capable of embossing five characters per 
second. Early in the twentieth century the rotary press 
was adapted to printing from these embossed plates. These 
two inventions have lowered the cost and increased the out- 
put of literature for blind readers. But as the demand is 
small and the books are bulky, the cost of paper and bind- 
ing is disproportionately high. David Copperfield in one 



THE BLIND— EDUCATION AND EMPLOYMENT 321 

dot type makes six volumes, as large as Webster's Un- 
abridged Dictionary, which are listed at $3.50 each, making 
the cost of a single copy $21.00. Since 1907 through the 
generosity of Mrs. Matilda Ziegler, blind readers have been 
furnished, free of cost, a monthly magazine containing sixty 
to sixty-five pages. With the adaptation and perfection 
of existing inventions to printing for the blind the cost of 
production will gradually be lowered with a corresponding 
increase in the amount of embossed literature. 

Since 1879 the National Government has appropriated 
$10,000 annually for the production of embossed literature 
which has been distributed pro rata upon a per capita basis 
to the various schools for the blind. The Howe Memorial 
Press, an adjunct of the Perkins Institution at Water- 
town, has an annual income of about $9000 which it may 
expend in the production of literature and of apparatus; 
and a number of schools and associations expend liberal 
amounts from private funds. 

The National Government conferred another great 
boon upon its sightless citizens through the Department of 
the Postmaster General by extending in June, 1904, the 
franking privilege to embossed books sent by a library to 
a blind reader or by a reader returned to the library. Prior 
to this time books could be sent only by mail or by express 
and the cost was so great as to be practically prohibitive. 
Since 1904 there has been an enormous increase in the cir- 
culation of embossed books and magazines (Fig. 115). 

The Employment or the Blind. — Two questions 
are usually asked by every interested visitor to a school for 
the blind. His first question is, " What trades and pro- 
fessions are open to the blind? " his second, " Can they 
become self-supporting? " 

He who lives and works among the blind and realizes 

21 



322 



HYGIENE OF THE EYE 




P. V 






^1 



s-q 



fl.9 









•5b-2 

a « 

'. a 



THE BLIND— EDUCATION AND EMPLOYMENT 323 

how varied are their talents is almost tempted to reply in 
answer to the first question: " There are few trades or pro- 
fessions from which the blind are excluded." So many 
factors enter into the problem that no general answer can 
be given. In spite of its frequent use in speech and in 
writing, the phrase " the blind " cannot be used in any 
generic sense; there is no such concept as "the blind." 
Persons without sight differ, precisely as those who see, in 
capabilities, in tastes, in character — in short in all matters 
that go to make personality. Some have keen intellects, 
some are dull and almost unteachable; some have a great 
deal of pride about their personal appearance, others are 
wholly devoid of any appreciation of its importance ; some 
have strong, sterling characters, others are weak, easily 
led, and are wholly undependable. 

The problem is further complicated by the age at which 
sight is lost. It is one thing to continue the education of a 
pupil who loses sight after his education is well begun; it 
is quite another thing to give adequate training to one who 
has never seen or who has become blind in early childhood, 
which is true of three-fourths of those who reach our schools 
for the blind. To aid the man who loses sight in adult 
life with a background of years of experience in a world 
where sight is the queen of the senses in readjusting him- 
self to changed conditions ; to show him how he can live and 
work as a blind man is not an easy task: but to provide 
the best training and the wisest vocational guidance for 
those who have never seen is a problem that sometimes 
seems almost to defy solution. But in spite of the obstacles, 
success has been won by the blind in many walks in life. 

For those who lack initiative or who have found it im- 
possible to succeed without guidance and assistance, in- 
dustrial homes, which are factories or workshops with a 



324 HYGIENE OF THE EYE 

boarding-house attachment, and workshops, which omit 
the boarding feature, have been found necessary. A few 
of these are supported by private funds, but nearly all of 
them receive state or municipal aid. While this method 
of furnishing employment seems necessary, many believe 
that every possible effort should be made to keep blind 
people in their own homes and communities. 

Piano tuning has been found to be one of the most 
remunerative employments for blind men who possess the 
requisite ear and mechanical ability. Some find this trade 
a stepping-stone to piano selling and later to successful 
careers as proprietors of music stores (Fig. 116). 

Others of less ability follow simpler and less remunera- 
tive employments, such as the reseating of cane chairs, 
hammock-making, tobacco-stripping, selling newspapers; 
one man has accumulated a competence by selling peanuts. 

Possessed of more ability, some have attained success 
in business and professional life. Totally blind men and 
women are successfully practising massage and osteopathy ; 
a young woman, with the help of her mother as a reader, 
reviews magazine articles and books before women's clubs ; 
another teaches English to foreigners in a large cosmopoli- 
tan city; still another teaches vocal music in the public 
schools of two cities in a central western state. A totally 
blind man has risen through piano tuning to the presidency 
of a large piano business, maintaining stores in five Cana- 
dian cities; another has acquired affluence as a real estate 
dealer. Without sight men have attained success and use- 
fulness in the law and the ministry. 

Eminent among educators of the blind are the names 
of two blind men, both knighted by the King of England 
after forty years of eminent service, Sir Francis Campbell, 
late principal of the Royal Normal College for the Blind, 



THE BLIND— EDUCATION AND EMPLOYMENT 325 




3^ HYGIENE OF THE EYE 

London, England, and Sir Frederick Fraser, superintend- 
ent of the Halifax (N. S.) School for the Blind; while a 
not inconsiderable number are individual and class-room 
teachers, teachers of music and of handicrafts in our schools 
for the blind. 

Blind men are representing their constituents in at 
least three State Legislatures; the voters of a Minnesota 
Congressional district recently elected a blind man as their 
Representative in Congress. Thomas P. Gore, United 
States Senator from Oklahoma, has been totally blind since 
fourteen years of age, John E. Swearingen, South Caro- 
lina's State Superintendent of Education, has been totally 
blind from eleven years of age; and Sir Henry Fawcett 
performed his greatest public service as England's blind 
Postmaster General. 

Nor has the field of literature been closed to the blind. 
Milton produced " Paradise Lost " after he became blind; 
though not entirely blind, Prescott and Parkman made 
their exhaustive historical researches and did their writing 
almost entirely through the eyes of their assistants, work- 
ing against odds that would have disheartened most men; 
totally blind from infancy, Fanny Crosby was the most 
prolific hymn writer of the nineteenth century; and such 
was his love for animals and nature and so keen were 
his observations that Clarence Hawkes before his loss of 
sight, at fourteen years of age, had laid the foundation that 
enables him to give us accurate stories of animal life which 
he does in charming language. 

This list of successful blind people could easily be ex- 
tended; but it is sufficiently long and varied to establish 
the truth that, while blindness imposes a fearful handicap, 
it does not prevent the attainment of the highest success 
and usefulness in manv fields of human endeavor. 



Name 

). Ganey, Resident Supt 

Mutes and Blind, J. S. Graves, 



THE United States. — Corrected February, 1916. 



Pupils 
enrolled Superintendent 
1914-1915 



108.. F. H. Manning. 



156 . .John H. Hinemon. 

ition of the Deaf and Dumb, and 94. .L. E. Milligan. 



5Und and Deaf Mutes 

klassachusetts School for the BUnd 



theBUnd 37. 

46. 

and the Blind 38 . 

113. 

f and the Blind 18 . 

210. 
ion of the Blind 143 . 

135. 

ation of the Blind 97 . 

ation of the Blind 145 . 

60. 

150. 

290. 
173. 
123. 

78. 
115. 

18. 

57. 

45. 
190. 
119. 
260. 

26. 
240. 

91. 

38. 
230. 
144. 

93. 

29. 
233. 
237 



id 

ion of the Blind 

and Dumb, and the Blind 



ation of the Blind . 



[..._ _ 

uction of the Blind 

nstitution for the Blind 

ation of the Deaf and Dumb, and 



the Blind. 



and Dumb and the Blind Colored 55 

I the Blind 34. 

Jlind 5. 

the Blind 76. 

r Colored Deaf and Blind 38. 

id 54. 

the Blind 83. 

136. 

and the Deaf and Dumb 

otal enrolment, 1914-1915 4860 



.W. K. Argo. 
.George H. Marshall. 
.A.H.Walker. 
.G. F. Oliphant. 
.W. E. Taylor. 
.H. C. Montgomery. 
.George S. Wilson. 
.George D. Eaton. 
.Isa A. Green. 
.Susan B. Merwin. 
.G. C. Huckaby. 

.John F. Bledsoe. 

.Edward E. Allen. 
.Clarence E. Holmes. 

J. J. Dow. 
.R. S. Curry, M.D. 
.S. M. Green. 
.H. T. Menzemer. 
.N. C. Abbott. 

R. R. Pratt. 
. Charles A. Hamilton. 
.Edward M. Van Cleve. 
.John E. Ray. 
.B. P. Chappie. 
.Chas. F. F. Campbell. 
.0. W. Stewart. 
.E. T. Moores. 
.0. H. Burritt. 
.T. S. McAloney. 
.N. F. Walker. 

.LeliaM. Curl. 
.J. V. Armstrong. 
.E. E. Bramlette. 
.J. J. Donaldson. 

.F. M. Driggs. 
Helen G. Throckmorton. 
W. A. Bowles. 
Wm. C. Ritter. 
Sadie E. Hall. 
Parley De Berry. 
J. T. Hooper. 

Dept. for the Blind not yet 
opened. 



state 



Residential School 



Place 



THE Blind in the United States. — Corrected February, 1916. 
■olle 



""■ne enrolled Superintendent 

1914-1915 

»i u fTaUadeea (School for the Blind, J. S. Ganey, Resident Supt 1 

^'*'""°'' \TaUadega ^"^""^ '<>'■ Negro Deaf Mutes and Blind, J. S. Graves, ^08.. F. H. Manning. 

[ Resident Supt. ) 

Ar^.»'"«? Little Rock School for the Blind 156 . .John H. Hinemon. 

Cahfomia Berkeley Institution for the Education of the Deaf and Dumb, and 94 L. E. MUlican 

the Blind 

Colorado Colorado Springs. SchooHor the Deaf and the Blind 37 W K Arso 

Connecticut. . . .Hartford Institute for the Bhnd .' . 46.' .George H Marshall. 

F'onda St. Augustine Institution for the Deaf and the Blmd 38 . . A. H. Walker. 

Georgia Macon Academy for the Blind 113. .G. F. Oliphant. 

Idaho Gooding State School for the Deaf and the Blind 18. .W. E. Taylor. 

Illinois Jacksonville School for the Blind 210. .H. C. Montgomery. 

Indiana Indianapolis Institute for the Education of the Bhnd 143 . . George S. Wilson. 

Iowa Vinton College for the Blind 135. .George D. Eaton. 

Kansas Kansas City Institution for the Education of the Blind 97 . . Isa A. Green. 

Kentucky Louisville Institution tor the Education of the Blind 146. .Susan B. Merwin. 

Louisiana Baton Rouge Institution for the Blind 60 . . G. C. Huckaby. 

M 1 J /Overlea School for the Bhnd 1 „„ ,. „ „i j 

'^"^'""'^ \Overlea School for the Colored Bhnd and Deaf Mutes / l^"' ■ J°'>'' ^- B''^'^«°«- 

Massachusetts. .Watertown Perkins Institution and Massachusetts School for the Blind «90. .Edward E. Allen. 

Michigan Lansing School for the Blind 173. Clarence E. Holmes. 

Minnesota Faribault School for the Blind 123. .J. J. Dow. 

Mississippi Jackson Institute for the Blind 78. .R. S. Curry, M.D. 

Missouri St. Louis School for the Blind 115. .S. M. Green. 

Montana Boulder .School for the Deaf and the Blind 18. .H. T. Menzemer. 

Nebraska Nebraska City . . .Institute for the Blind 67. .N. C. Abbott. 

New Mexico.. . . Alamogordo Institute for the Blind 46. .R. R. Pratt. 

XT V 1, /Batavia State School for the Blind 190. .Charles A. Hamilton. 

^^"^ ^°^'^ \New York City. .Institute for the Education of the Blind 119. .Edward M. Van Cleve. 

North Carolina . Raleigh Institution for the Deaf and Dumb, and the Blind 260 . . John E. Ray. 

North DakoU. .Bathgate School for the Blind 26. .B. P. Chappie. 

Ohio Columbus Institution for the Education of the iJlind 240. .Chas. F. F. Campbell. 

Oklahoma Muskogee School for the Bhnd 91 . .0. W. Stewart. 

Oregon Salem Institution for the Bhnd 38. .E. T. Moores. 

„ , . /Philadelphia Institution for the Instruction of the Blind 230. .0. H. Burritt. 

Pennsylvania. . ^Pittsburgh Western Pennsylvania Institution for the Blind 144 . .T. S. McAloney. 

South Carolina . Cedar Spring Institution for the Education of the Deaf and Dumb, and 93 . . N. F. Walker. 



South Dakota . . Gary School for the Blind 

Tennessee Nashville School for the Blind 

/Austin Institution for the Blind. 



.Lelia M. Curl. 
.J. V. Armstrong. 
237. .E.E. Bramlette. 



Texas \ Austin institution for the Deaf and Dumb and the Blind Colored 65 . . J. J. Donaldson. 

Youth 

Utah Ogden School for the Deaf and the Blind 34. .P. M. Driggs, 

Vermont Brattleboro Austine School for the Blind 



Virginia 

Washington . . 
West Virginia. 



[Staunton 
\Newport News, 

.Vancouver 

.Romney 

.Janesvill 



.School for the Deaf and t 



Helen G. Throckmorto 
W.A.Bowles. 

Virginia State School for Colored Deaf and Blind 38. .Wm. C. Ritter. 

State School for the Blind 64. .Sadie E. Hall. 

School for the Deaf and the Blind 83 . . Parley De Berry. 

136.. J. T. Hooper. 



Wyoming.. .. '. '. ! Cheyenne Institution for the Blind and the Deaf and Dumb. 



Total enrohnent, 1914-1915 4860 



Dept. for the 1 
opened. 



CHAPTER XX 

THE POPULAR MOVEMENT FOR CONSERVATION 

OF VISION 

By Edward M. Van Cleve 

managing director of the national committee for 

the prevention of blindness 

" Public health is purchasable; within natural limita- 
tions a community can determine its own death rate." This 
is the forceful declaration of the City and State Boards of 
Health of New York. Its truth is being accepted and 
proved more generally all the while. The corollary that 
human powers can be conserved by taking thought is capa- 
ble of demonstration in similar fashion. In the field of 
conservation of vision this truth is accepted, that correct 
knowledge of the means of avoiding harm to the eyes is 
the surest road to saving sight, and the only purchase price 
that is demanded is the effort made in securing that knowl- 
edge. It is monstrous to think that any parent is willing 
to let his child go blind if he knows the condition that will 
inevitably bring on this calamity and knows the means of 
prevention. For his child he will buy at any cost safety 
from so great a calamity as losing sight. Enlightened 
self-interest will lead the individual to care for his own eyes. 

The movement for the conservation of vision is to-day 
an educational movement concerning itself with bringing 
to general attention the knowledge of specialists in saving 
sight for the individual threatened or already in peril, that 
society may be spared the increase of inefficiency through 
the addition of handicapped men and women, and that the 
public burden of providing for such handicapped persons 
may be lessened. Conservation of vision is first a personal 
interest; it becomes a social interest, even a public interest. 

327 



328 HYGIENE OF THE EYE 

Whoever learns that half of all blindness is preventable 
experiences some sort of emotion. It may be only a mild 
wonder why somebody does not do something about the 
matter, or it may assume the opposite extreme of a burning 
indignation or a divine pity inspiring action — vigorous, 
persistent, effective. The discovery of Crede, in 1881, that 
the instillation of a solution of a silver salt at the time of 
birth in the eyes of the new-born babe will almost invariably 
kill the germ which produces much blindness and impair- 
ment of vision in babyhood, gave rise to widespread dis- 
cussion by physicians and an effort to secure the general 
use of the so-called Crede method. Success in reducing 
to a minimum the cases of visual impairment, by this or a 
similar method, wherever used, has given life to the en- 
deavor of organizations and interested individuals to make 
it a matter of universal knowledge that blindness from 
inflammation in the eyes of the new-born is needless. To 
accomplish this education of the public, recourse is had to 
the newspaper, the popular magazine, the printed leaflet — 
all the devices of advertising; also to the popular lecture 
and the moving picture. 

Other causes of blindness or reduced vision in childhood 
claim attention. Ocular tuberculosis, interstitial keratitis, 
eye troubles following measles and scarlet fever, synipa- 
thetic ophthalmia, and progressive near-sightedness are 
chief of these. Intelligence in handling these diseases comes 
from spreading knowledge of their danger and directing 
their victims to proper care. 

Trachoma attacks both child and adult. It thrives in 
Ignorance and neglect. Glaucoma in adults comes on in- 
sidiously and the warnings of its approach are neglected 
because unrecognized. In the industries, in the schools, in 
the home, eye-strain is endured without consideration of its 



MOVEMENT FOR CONSERVATION OF VISION 329 

calamitous effects. Yet all of these causes of visual im- 
pairment may usually be avoided. It is the purpose of the 
societies organized for the conservation of vision to bring 
about universal knowledge of these facts. 

The National Committee for the Prevention of Blind- 
ness^ is engaged in this work of educating the public. It 
serves as a clearing-house of information for all persons 
interested in this effort to save sight. It prepares popular 
literature and publishes it or furnishes the material for 
articles to magazines, newspapers, and to individuals. It 
has a large collection of lantern slides for use in illustrat- 
ing lectures on the subject of conservation of vision. It 
provides a lecture sei-^^ice by its own staff and lends assist- 
ance to lecturers seeking help in preparing to present the 
facts. It aids in the organization of societies and com- 
mittees in states and cities, it advises in the passage of laws, 
it provides expert service in every field for promotion of 
this cause (see Figs. 117 and 118) . 

The American JNIedical Association, through its Com- 
mittee on Health and Public Education with a sub-com- 
mittee on Conservation of Vision, secures publication of 
pamphlets on many subjects concerning care of the eyes, 
and provides for the press of the country a news service 
which is widely used. This committee also promotes legis- 
lation and maintains a lecture bureau for instruction of the 
people, using the unpaid services of public-spirited mem- 
bers of the medical profession. 

Superintendents of schools for the blind, who are in a 
position to know how much the blindness that is prevent- 
able costs the individual and the State, have been active 
in the task of spreading the knowledge of possible preven- 

^ This Committee has its office at 130 East 22d Street, New 
York City. 



330 



HYGIENE OF THE EYE 




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45 S m 2? 
•1 S ¥•? 


^2^1 


EEYE 

ous di 




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^^ = J 


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ic^f 


^^f - ^^^ 


ca 


^Cv^ 


^^^^ 




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^I^^PK^^^;i^ 


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O 



MOVEMENT FOR CONSERVATION OF VISION 331 

tion. For years the publications of the schools for the 
blind have included directions for prevention of needless 
blindness. 

Societies, committees, State commissions, and inter- 
ested individuals have undertaken not only educational 
work but remedial effort. An example of the sort of ser- 
vice that may be rendered is shown in the admirable " fol- 
low-up " work possible in Boston through the cooperation 
of several organizations. Thus, a case is reported by an 
agent of the Commission for the Blind or by doctor or 
nurse to the Board of Health which sends a city nurse to 
investigate. If necessary, the child (and sometimes the 
mother with the child) is transferred to the Eye and Ear 
Infirmary for treatment and care, and the hospital through 
its social service department helps the mother and visits 
the family after the child's discharge to see that the direc- 
tions of the doctor are carried out. This kindly care is 
kept up until the result aimed at is attained — a well child. 
Such " follow-up " work is very important in cases of oph- 
thalmia neonatorum, but it is also valuable in other kinds 
of eye trouble, and the social service department is coming 
to be considered an indispensable part of any well organ- 
ized hospital, including general as well as special hospitals. 

Such is the character of the work done in the movement 
for conservation of vision. That success is attending the 
efforts of the workers is evidenced by a gradual but steady 
lessening of the number of children entering the schools for 
the blind who have been rendered sightless through pre- 
ventable causes. For many years, however, effort must be 
continued and the scope of the work broadened until there 
is wiped out the reproach on our civilization of allowing 
any person to go through life with sight lost or seriously 
impaired from preventable causes. 



INDEX 



Accommodation, 17 

power of, 18 
Acromegaly, eye changes in, 231 
Adenoids, cause of eye changes, 225 
Albinism, 171 
Albinos, choroid in, 7 

iris of, 10 
Alcohol, cause of color-blindness, 282 

effect of, on eyes, 275 
ethyl, 275 

methyl or wood, 261 
Alphabets for the blind, 304 

American Braille system, 305, 306 

Boston line type, 305 

Braille system, 305 

Hauy's system, 304 

New York point type, 305 

Philadelphia line type, 305 
Amblyopia, alcoholic, 276 

tobacco (see Blindness), 273 
Ansemia, cause of eye changes, 206 
Anisometropia, 45 
Antimetropia, 45 
Aqueous humor, 11 
Artificial lighting, 101 

contrasts to be avoided, 107 

direction of, 108 

fixtures, types of, 114 

from architectural standpoint, 117 

furniture and wall coverings of im- 
portance, 115 

illumination diffused, 106 
directed, 106 

light, quantity of, 116 

sources, large and small, 106 

lights, arrangement of, 101, 110 
kinds of, 101 

position of individual in relation to, 116 
shades and reflectors, 103 



Asthenopia, 61 

muscular, 22 
Astigmatism, 17, 42 

compound, 17, 42, 45 

correction of, 44 

hypermetropic, 42 

irregular, 42 

mixed, 17 

myopic, 42 

regular, 42 

simple, 17 

symptoms of, 43 
Atropine as a cycloplegic, 30 

constitutional symptoms resulting 
from, 31 

glaucoma produced by, 32 

in myopia, 39 

objections to, 31 

value of, 30 

Bacillus, Koch-Weeks, 151 

Morax-Axenfeld, 152 
Basedow's disease, 226 
Beverages, effect of, on eyes, 273 
Blepharitis marginitis, 154 
Blind, the, 283 

children, education of, 287 

nurseries for, 286 
co-education with seeing pupils, 317 
advantages of, 318 
disadvantages of, 318 
education of, 287 

advanced courses, 319 
American alphabets, 304 
Boston line type, 305 
Braille system, 305 
Philadelphia line type, 305 
drawing, 310 

333 



334 



INDEX 



Blind, education of, embossed books 
for finger readers, 320 
history of, 287, 302 

Hauy's raised characters, 302 
literary department, 300 
geography, 312 
history, 312 
languages, 310 
mathematics, 310 
reading, 302 
-writing, 307 

Hall Braille machine, 308 
pencil, 308 
provisions for, 286 
sciences, 313 
typewriting, 313 

commercial work, 314 
employment of, 321, 324 
as instructors, 324 
as literary writers, 326 
as national and state ofiacials, 326 
as piano-tuners, 324 
industrial homes for, 323 
literature for, 320 

free transportation of, 321 
monthly magazine, 321 
music as a vocation of, 314 
musical education of, 314 
number of, in schools, 284 
physical training of, 289, 291 
athletic field, 294 
bowling, 292 
football, 296 
gymnasium, 291 
running races, 294 
swimming pools, 292 
schools for, 287 

age of admission, 288 

length of time in, 289 

spot, Mariotte's, 21 

training of the hand, 296 

domestic science, 300 

manual arts, 298 

occupations, 300 



Blindness, 283 
alcoholic, 276 
causes of, 283, 328 
iodoform, use of, 278 
obstruction of retinal artery, 174 
ophthalmia neonatorum, 283 

statistics, 284 
poisoning, by lead, 263 

methyl or wood alcohol, 261 
quinine, 277 
salicylic acid, 278 
vascular disease, 174 
vermifuges, 278 
classification by age and sex, 285 
color (see Color-blindness), 279 
night, 175 

partial, in tea and coffee drinkers, 27^ 
prevention of, 328 

Crede's method, 328 
sudden total, in one eye, 175 
ratio of cases to population, 285 
relation of consanguinity to, 176 
tobacco, 273 

prevention of, 274 
symptoms, 274 
Blood diseases, cause of eye changes, 206 
anaemia, 206 
leukaemia, 207 
Blood-vessels, disease of, cause of eye 
changes, 208 
of eyeball, 11 
Brain tumor, eye changes in, 178 
Bright's disease cause of eye changes, 20& 
Burritt, on blindness, 283 

Cancer of eyelids, 154 
Car sickness, 65 
Cataract, 171, 185 

age in relation to, 185 

of childhood, 186 

congenital, 185 
operation for, 191 

cure of, 190 

definition of, 185 



INDEX 



335 



Cataract, diagnosis of, 189 
due to Bright's disease, 188 
diabetes, 188, 212 
excessive heat and light, 188 
eye-strain, 188 
iritis, 167 
early symptoms of, 186 
electric, 257 
hereditary, 185 
lamellar, 208 

muscse, symptomatic of, 181 
operation for, 190 

delirium following, 230 
prognosis, 193 
technique, 191 
time for, 194 
progression of, 187 
senile, 186 
treatment of, 189 
by absorption, 190 
by dionine, 190 
immature form, 189 
incipient stage, 189 
mature form, 189 
zonular, 208 
Catarrh, epidemic conjunctival, 151 
Chalazion, 156 

Chocolate drinking, effect of, on eyes, 27C 
Chorea of eye-strain, 65 
Choroid, 7 

diseases of, 171 
albinism, 171 
coloboma, 171 
inflammation, 172 
malignant tumors of, 173 
of albinos, 7 
Choroiditis, 172 
causes of, 172 

tuberculosis, 172 
diagnosis, 172 
suppurative, 173 
Ciliary body, 9 
injuries of, 240 
muscle, action of, in farsightedness, 27 



Ciliary muscle, normal, 26 

Coffee drinking, effect of, on eyes, 276 

Coloboma, of choroid, 171 

of iris, 167, 171 
Color-blindness, 279 
acquired, 280 

cause of, 280 
caused by alcohol and tobacco, 282 
congenital, 280 
hereditary, 280 
history of, 279 
Holmgren color test, 281 
in relation to occupation, 280 
lantern test for, 281 
partial, 280 
total, 280 
Color field, 20 
Conjunctiva, 5, 127 
diseases of, 127 
inflammation of, 127 
soil for microorganisms, 127 
Conjunctivitis, 127 
acute catarrhal, 151 
contagiousness of, 151 
Koch- Weeks bacillus, 151 
angular, 152 

due to diseases of general system, 129 
errors of refraction, 128 
various microorganisms, 152 
epidemic catarrhal, 128 
follicular, 150 

granular (see Trachoma), 142 
metastatic gonorrhoeal, 141 
treatment of, 141 
women rarely affected by, 142 
prevented by colored protecting glasses, 

129 
purulent, of adults, 139 
course of, 140 

due to gonorrhoeal infection, 139 
treatment of, 140 
to vaginitis, 142 
of infants (see Ophthalmia Neona- 
torum), 129 



336 



INDEX 



Conjunctivitis, subacute, 151 

Morax-Axenfeld bacillus, 152 
Cornea, 7 

disease of (Keratitis), 162 

eczema of, 162 

foreign body on, 234 

jagged tears of, 239 

perforating injury of, 238 

scratches of, 236 
Crede's method for prevention of blind- 
ness, 328 
Cross-eye (see Squint), 28, 52 
Cycloplegics, 30 

atropine, 30 

use of, in astigmatism, 45 
in hypermetropia, 29 
in myopia, 45 
Crystalline lens, 9 

hardening of, 46 

removal of, in myopia, 41 

Dalrymple sign, 227 

Daylight illumination, from architec- 
tural standpoint, 117, 119 
factory buildings, 119 
prismatic glass, 122 

vault lights, 126 
school buildings, 120 
skylights, 125 
Decompression operation, 179 
Dental affections, eye changes in, 224 
Diabetes, ocular changes due to, 210 

cataract, 212 
Digestive disturbances, due to eye-strain, 

62 
Double vision, 3, 22 ' 
Drugs, effect of, on eyes, 273 
injurious to vision, 277 
iodoform, 278 
quinine, 277 
salicylic acid, 278 
vermifuges, 278 

Ear, diseases of, eye changes in, 225 
Epilepsy, ocular phenomena of, 71 



Eyes, blind, divergence of, 58 
care of, 73 

automobiling, 98, 99 
in adults, 96 
bathing, 98 
moving pictures, 99 
physical condition, 98 
reading, 97 

in recumbent posture, 97 
veils, 97 
changes in, due to disease, 205 
adenoids, 225 
acromegaly, 231 
anaemia, 206 
cardiac disease, 209 
chlorosis, 206 
deformities of skull, 230 
dental affections, 224 
diabetes, 210 
exophthalmic goitre, 226 
infantile paralysis, 232 
infectious diseases, 212 
cholera, 216 
diphtheria, 214 
erysipelas, 215 
influenza, 215 
leprosy, 216 
malaria, 215 
measles, 212 
mumps, 216 
scarlet fever, 213 
small-pox, 214 
tuberculosis, 216 
typhoid fever, 215 
whooping-cough, 216 
leukaemia, 207 
lightning stroke, 246 
of blood-vessels, 208 
of ear, 225 

of kidneys (Bright's disease), 209 
of nervous system, 227 
hysteria, 229 
insanity, 229 

general paralysis of, 230 



INDEX 



337 



Eyes, changes in, due to disease of 
nervous system, meningitis, 228 
of respiratory tract, 224 
of skin, 223 

phthiriasis, 224 
of spinal cord, 231 

locomotor ataxia, 231 
of sexual organs, 220 

abnormal menstruation, 220 
menopause, 220 
pregnancy, 221 

kidney disease of, 221 
pernicious antemia, 207 
poliomyelitis, anterior, 232 
rhachitis (rickets), 208 
venereal diseases, 218 
gonorrhoea, 218 
syphilis, 218 
color of, 10 

defects of, cause of car sickness, 65 
vertigo, 64 
correction of, economic value of, 84 
influence of, on digestive system, 62 
on general organism, 59 
on nervous system, 59 
eflFect on, of alcohol, 275 
of drugs (see Drugs), 277 
of school life, 33 
of tobacco, 273 
emmetropic, 16 
examination of, before entering school 

life, 75 
far-sighted, 16 
foreign bodies in, 233 

removal of, 234 
function of, 12 
fundus of, ophthalmoscopic appearance 

of, 25 
hypermetropic, 16 
in diseases of general system, 205 
ophthalmoscopic examination of im- 
portance, 205 
involvement of, 205 
infection of, 128 



Eyes, interior of, diseases of, 171 
length of, 16 
myopic, 17 
near-sighted, 17 
of normal length, 16 
ophthalmic picture of, 25 
shape of, 6 
structure of, 1 

aqueous humor, 11 
choroid, 7 
ciliary body, 9 
conjunctiva, 5 
cornea, 7 
crystalline lens, 9 
external muscles, 3 
eyelids, 3 
iris, 10 

lachrymal gland, 5 
lashes, 4 
orbit, 1 
pupil, 11 
retina, 7 
sclerotic, 7 
vitreous humor, 10 
wounds and injuries of, 233 
agricultural, 259 
by blows from balls, 242 
• burns, 236 

chemical, 237, 261 
in childbirth, 223 
from golf ball explosions, 244 
gun-shot, 241 
household, 260 

chemicals, 261 
due to improper lighting, 263 
industrial, 246 

from blasting operations, 256 
from breaking tools, 255 
bums by molten metal, 247 
from bursting gauges, 252 
from electric flashes, 257 
from emery wheels, 253 
excessive heat and light rays, 256 



338 



INDEX 



Eyes, wounds and injuries of, indus- 
trial, prevention of, 264 
first aid service, 265 
goggles, 267 
warning placards, 266 
statistics, 246 

to bottlers of aerated waters, 258 
to chippers, 251 
perforation of globe, 238 
from slingshots, 242 
sympathetic inflammation, 240 
Eyeball, blood-vessels of, 11 
nerves of, 11 
oscillations of, 70 
and head jerking, 70 
Eyeglasses and spectacles (see Spectacles), 

26, 47 
Eye-lashes, 4 

displacement of, 157 
Eyelids, 3 

disease of, 154 

blepharitis marginitis, 154 
cancer, 154 
chalazion, 156 
growths, benign, 154 

malignant, 154 
herpes zoster, 158 
hordeolum, 155 
ptosis, 157 
styes, 155 
injuries of, 236 
irregularities of contour, 157 
movements of, 5 
Eye muscles, paralysis of, head position 

in, 66 
Eye-strain, associated with epilepsy, 71 
cause of bed wetting, 66 
of cataract, 188 
of chorea, 65 

of contractions of facial muscles, 69 
of faulty position of head, 66 
of headache, 60 

of spasmodic head movements, 66 
of wry-neck, 70 



Eye-strain, symptoms, absence of, in, 61 
Exophthalmic goitre, 226 

Factory buildings, daylight illmnination 

of, 119 
Farsightedness (see Hypermetropia), 26 
Field of vision, 19 

Floating bodies, in vitreous hmnor, 182 
Foreign bodies, 233 
on cornea, 234 
removal of, 234 

inflammation arising from, 235 
treatment after, 235 
in eye, 233 

removal of, 234 
Fortification spectrum, 183 
Fovea centralis, ophthalmoscopic appear- 
ance of, 25 
Fundus of eye, ophthalmoscopic appear- 
ance of, 25 
Furber, on Daylight Illumination, 117 

Gland, lachrymal, 5 
Glaucoma, 171, 196 
acute fulminating, 196 
age in relation to, 204 
chronic, 196 

diagnosis, by ophthalmoscope, 198 

by tonometer, 199 
treatment of, by myotics, 203 
operative, 203 
definition of, 196 
early recognition, 197 
following iritis, 167 
inflammatory, 170, 196 
diagnosis, 199 
operation for, 198 
iridectomy, 202 
trephining, 202 
symptoms, 199 
predisposing causes, 204 
age, 204 
heredity, 204 
prevention of, 328 
primary, 197 



INDEX 



339 



Glaucoma, produced by atropine, 32 
prognosis of, 198 
secondary, 197 
subacute, 196 
symptoms, 197 
Glioma, 177 

Goggles, value of, in preventing accidents, 
267 
color of glass, 272 
statistics, 269 
special forms of, 

Pfund's lens for heat radiations, 271 
for various occupations, 270 
Gonorrhoea, 132 

cause of purulent conjunctivitis in 
adults, 139 
in infants, 132 
of iritis, 168 
Graefe sign, 227 
Graves' disease, 226 

Head jerking and oscillations of eyeballs, 

70 
Headache, due to eye strain, 60 
Heart, disease of, eye changes in, 209 
Hemeralopia, 175 
Hemianopsia, 21 

significant of brain disease, 21 
Herpes zoster, 158 
Heterophoria, 22 
Holmgren color test, 281 
Hordeolum, 155 
Hyperaemia, hypermetropic, 28 
Hypermetropia, 26, 46 

correction of, 29 

optic principles involved, 29 

hyperseraia of, 28 

muscular activity in, 27 

Illumination, diffused, 106 

directed, 106 

proper, effect of, on output of work, 126 

of workshops, 263 
Infantile paralysis, eye changes in, 232 



Infectious diseases, ocular changes in, 212 
cholera, 216 
diphtheria, 214 
erysipelas, 215 
influenza, 215 
leprosy, 216 
malaria, 215 
measles, 212 
mumps, 216 
scarlet fever, 213 
small-pox, 214 
tuberculosis, 216 
typhoid fever, 215 
whooping-cough, 216 
Iridectomy, for glaucoma, 201 
Iris, 10 

of albinos, 10 
diseases of, 167 

iritis, 167 
malformations, congenital, 167 

coloboma, 167 
perforating injury of, 239 
Iritis, 167 

causes of, 168 

articular rheumatism, 168 
gonorrhoea, 168 
rheumatoid arthritis, 169 
syphilis, 168 
tuberculosis, 169 
diagnosis of, 169 
symptoms, 167 
treatment, 169 
Ives, on Artificial Lighting, 101 

Keratitis, 162 
interstitial, 164 
causes of, 165 
syphilitic, 165 
prognosis of, 166 
symptoms, 165 
phlyctenular, 162 
course of, 162 
treatment, 163 
tubercular, 217 



340 



INDEX 



Kidney disease, ocular changes due to, 209 

of pregnancy, eye changes in, 221 
Kryptok lens, 50 
Koch- Weeks bacillus, 151 

Lachrymal apparatus, diseases of, 159 
congenital, 160 
inflammation of sac, 160 
lachrymation, 159 

cause of, 160 
treatment, 161 
gland, 5 
Lead poisoning, 263 
Lens, perforating injury of, 239 
Lenses, 14 
Kryptok, 50 
periscopic, 50 
toric, 50 
Leukaemia, eye changes in, 207 
Lighting, artificial (see Artificial Light- 
ing), 101 
fixtures, 114 

natural (see Daylight Illumination), 
117, 119 
Lightning stroke, effect of, on eyes, 246 
Locomotor ataxia, eye changes in, 231 
Loring's ophthalmoscope, 24 

Macula lutea, 20 

ophthalmoscopic appearance of, 25 
Mariotte's blind spot, 21 
Mastoid abscess, eye changes in, 226 
Methyl or wood alcohol poisoning, 261 
Migraine, due to eye-strain, 61 
Miner's nystagmus, 71 
Morax-Axenfeld bacillus, 152 
Motes, 180 

Moulthrop school chair, 77 
Muscse, 180 

volitantes, 37, 182 
Muscle, ciliary, function of, 26 
Muscles of eye, division of, in myopia, 41 

external, 3 
IMuscular asthenopia, 22 



Mydriatics, 30 

atropine, 30 
Myopes, school life of (see School Life), 87 
Myopia, 33, 46 

age of arrest of progression, 33 
of development, 33 

atropine, value of, in, 39 

causes of, 33 

changes of vitreous in, 37 

correction of, 39 
importance of, 38 

detachment of retina in, 37 

diagnosis of, 36 

division of eye muscles in, 41 

frequency of examinations in, 40 

glasses, constant use of, in, 40 

hereditary influence, 33 

motes of, 183 

ophthalmoscopic examination for, 36 

a pathological condition, -37 

prevention of, 38 
importance of, 38 

progressive character of, 33 

racial tendency, 32, 35 

removal of crystalline lens in, 41 
Myotics, 203 

Near-sightedness, 32 
Nerves of eyeball, 11 

Nervous system, diseases of, eye changes 
in, 227 
hysteria, 229 
insanity, 229 

general paralysis of, 230 
meningitis, 228 
influence of optical defects on, 59 
Nystagmus, 70, 226 
hereditary, 70 
miner's, 71 
cure of, 71 

Ocular muscles, 22 

functional anomalies of, 22 
vertigo, 64 



INDEX 



341 



©phthalmia, gonorrhoeal, of adults, 139 
of infants, 129 
metastatic, 141 
neonatorum, 129 

blindness due to, 283 

statistics, 284 
cause of, 131 

gonorrhoeal infection, 132 
contagiousness, 131 
course of, 130 
innocent type, 132 
onset of, 129 
prognosis, 139 
treatment of, 133 

Department of Health instructions, 
for child at birth, 137 
when inflammation of eyes 

appears, 138 
during pregnancy, 136 
silver nitrate, 133 
stringent State laws, 134 
Ophthalmoscope, 12, 23 
Loring's, 24 

method of illumination, 23 
Optic foramen, 3 
nerve, 25, 177 

changes in, in brain tumor, 178 
inflammation of, 178 
neuritis, 177 

in brain tumor, 178 
cause of, 179 

decompression operation, 179 
diagnosis, 178 
Optical defects, influence of, on general 

system, 59 
Orbit, 1 

diseases of, 158 
margins of, 3 
shape of, 2 

racial differences in, 2 
walls of, 3 

Perceptions, visual, 180 
Perimeter, 21 



Peripheral perception, 20 
Periscopic lens, 50 
Pfund's lens, 271 
Phosphenes, 180 
Physiology of vision, 12 
Pinguecula, 153 
Pink eye, 151 
Poisoning, lead, 263 

methyl or wood alcohol, 261 
Poliomyelitis, anterior, eye changes in, 

232 
Power of accommodation, 18 
Presbyopia, 46 

correction of, 47 

of old sight, 18 
Princeton adjustable school desk and 

chair, 78 
Prismatic glass, 124 

use of, in manufacturing buildings, 
125 
in school buildings, 122 

vault lights, 126 
Prisms, 15 

Pseudopterygium, 153 
Pterygium, 153 
Ptosis, 157 

congenital, 157 

treatment, 157 
Pupil, 10 

size of, 11 

Reading in recumbent posture, 97 
Refraction, 16 
anomalies of, 26 
correction of, 26 
anisometropia, 45 
antimetropia, 45 
astigmatism, 42 
presbyopia, 46 
far-sightedness, 26 
hypermetropia, 26 
myopia, 32 
near-sightedness, 32 



342 



INDEX 



Hefraction, anomalies of, cause of con- 
junctivitis, 128 
of squint, 52 
ophthalmoscopic measurement of, 25 
Respiratory tract, diseases of, eye changes 

in, 224 
Retina, 7 

detachment of, 176 

treatment, 176 
diseases of, 174 
light-perceiving elements of, 7 
pigmentary degeneration of, 175 
tumors of, 177 
gUoma, 177 
Retinitis, 174 
causes of, 174 
syphilis, 175 
of pregnancy, 221 
Retinoscopy, 25 

Rhachitis, eye changes due to, 208 
Rheumatism, articular, cause of iritis, 168 

School buildings, daylight illumination 
of, 120 
southern exposure preferable, 122 
inspection, medical, 84 
life, 73, 75 

adequate lighting, 77 
blackboards, 81 
books, composition of, 82 
size of type in, 83 
examples of, 85 
examination of eyes, 75 
faulty postures, 80 
length of lesson periods, 76 
medical inspection, 84 

economic value of, 84 
of myopes, 87 
classroom, 88 
curriculum, 89 
manual training, 90 
for boys, 93 
for girls, 93 
physical training, 90 
of partially sighted, 94 



School life, proper seating, 77 

special classes for pupils with defect- 
ive sight, 86, 96 
London methods, 87 
style of writing, 82 
rooms, lighting of, 118, 120 
prismatic glass, 122 
Sclerotic, 6 
Scotoma, 21 
Second sight, 41 
Sexual organs, diseases of, eye changes in 

(see Eyes, changes in), 220 
Shadow test, 25 
Sight, physiology of, 12 
Sign, Dalrymple, 227 

Graefe, 227 
Skin diseases, eye changes in, 223 
Skull, deformities of, cause of eye 

changes 230 
Skylights, 125 

artificial, 125 
Snow blindness, 245 
Sparks, 180 

Spectacles and eye-glasses, 26, 47 
adjustment of, 48, 51 

for near use, 50 
bifocal, 48 
choice of, 48 

colored or tinted lenses, 31 
"fronts," 50 
Kryptok lens, 50 
periscopic lens, 50 
toric lens, 50 
size of, 50 
Spinal cord, diseases of, ocular changes 
in, 231 
curvatures, due to school seating, 80 
Squint, 52 
causes of, 52 
congenital, 52, 56 
correction of, 57 
operative treatment, 57 
advancement, 57 
tenotomy, 57 



INDEX 



343 



Squint, convergent, 54 
correction of, 54 

divergent, 56 

due to errors of refraction, 52 

paralytic, 52 
St. Vitus' dance, due to eye-strain, 65 
Strabismus (see Squiut), 28, 52 
Styes, 155 

abortion of, 155 

treatment, 155 
Syphilis, 218 

acquired, 219 

cause of interstitial keratitis, 165 
of iritis, 168 

hereditary, 219 

Tea drinking, effect of, on eyes, 276 
Tear sac, 6 
Test shadow. 25 

Holmgren color, 281 
lantern, 281 
Tobacco, cause of color-blindness, 282 
blindness, 273 

prevention of, 274 
symptoms, 274 
Toric lens, 50 
Trachoma, 142 
acute stage, 142 
among school children, 147, 148 
contagiousness, 145 
control of, in adults, 148 

•among school children, 148 
course, 142 
curability, 144 
detection of, 150 
a disease of poverty, 146 
eyelids in, 157 
history of, 145 
prevention of, 148, 328 

rules for, 149 
regions of its occurrence, 146 
Trephining for glaucoma, 202 
Tuberculosis a cause of iritis, 169 



Tumor, of brain, optic neuritis in, 178 
of choroid, 173 
of retiua, 177 

Van Cleve, on Conservation of Vision, 327 
Veils, weariug of, 97 
Venereal diseases, eye changes in, 218 
gonorrhoea, 218 
syphiHs, 218 
Vertigo, 64 
ocular, 64 

treatment of, 65 
Vision, binocular, 21 
conservation of, 327 

Boston "follow up" system, 331 
causes of blindness, 328 
education of public by American 
Medical Association, 329 
by National Committee for Pre- 
vention of Blindness, 329 
by superintendents of schools, 
329 
prevention of bhndness, 328 
Crede method, 328 
direct, 19 
double, 3, 22 
field of, 18 
defects in, 21 
hemianopsia, 21 
scotoma, 21 
small blind areas, 21 
for color, 20 
indirect, 20 
physiology of, 12 
accommodation, 17 
lenses, 14 
ocular muscles, 22 
prisms, 15 
visual acuity, 18 
field, 19 
Visual acuity, 18 
perceptions, 180 

fortification spectrum, 183 
motes, 180 



344 



INDEX 



Visual perceptions, muscse, expression of 
disease, 181 
physiological, 180 

muscse volitantes, 182 

of epilepsy, 183 

of insanity, 183 

of migraine, 184 

phosphenes, 180 

sparks, 180 
Vitreous humor, 10 

diseases of, 170 

floating bodies in, 182 

penetrating wounds of, 240 

Wall-eyed, 56 

Wetting of bed, due to eye-strain, 66 
White of the eye, 7 
Wild hairs, 4, 157 
Window of the eye, 7 
Wounds and injuries of eyes, 233 
agricultural, 259 
of cornea, 234 
due to blows by balls, 242 
golf ball explosions, 244 
gmishot, 241 
improper lighting, 263 



Wounds and injuries of eyes, slingshot, 242 
household, 260 

chemicals, 261 
industrial, 246 

from blasting operations, 256 
from breaking tools, 255 
from bursting gauge, 252 
from electric flashes, 257 
from emery wheels, 253 
from molten metal, 247 
to bottlers of aerated waters, 258 
to chippers, 251 
prevention of, 264 
first aid service, 265 
goggles, 267 
statistics, 246 
warning placards, 266 
of lids, 236 

perforation of ciliary body, 240 
of globe, 238 
of iris, 239 
of lens, 239 
of vitreous, 240 

sympathetic inflammation, 240 
Wry-neck, due to paralysis of ocular 
muscles, 70 



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